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    Medications in Labor

    Guidelines

    • The quality of the childbirth experience is not determined by whether or not medications are used.


    • All medications affect the baby in some way, but with careful monitoring, serious side effects are rare.


    • All medications affect labor and the baby in some way.
    Medications may be used for many reasons, such as:
    • Medical reasons: including high blood pressure or lack of progress.


    • The mother's extreme discomfort due to the position of the baby, the strength of the contractions, or the length of labor.


    • Fatigue due to a long, hard labor.
    How the decision is made:
    • Your physician/midwife and anesthesiologist will discuss your options for pain relief and offer suggestions based on your individual needs.


    • The staff will work with you and suggest alternative pain relief measures to medications, if desired.
    The Labor Partner's Role Regarding Medication:
    • Know the mother's feeling about medications before labor begins.


    • The first time she requests medication, ask her if she would like more support and encouragement.


    • It is helpful to know how far along she is in labor before making a decision concerning medication. For example, your decision to take medication may be affected by the knowledge that you are 9 versus 6 centimeters dilated.


    • Try to avoid making a decision during a contraction. You are both most vulnerable at this time.


    • Provide the mother with support regardless of the decision she makes.
    Ways to Minimize the Need for Medication:
    • Have realistic expectations of labor - hard work, sweat and tears. Labor is similar to running a marathon: very hard work with a great reward.


    • Work with your labor, take each contraction one at a time, and have confidence in your body.


    • Accept coaching and staff support.


    • Nap when you can in order to minimize fatigue in late pregnancy.
    In order to give you informed consent for a suggested procedure or medication, you may want to consider the following questions with your care providers:
    • What is the purpose?


    • What are the perceived benefits and risks?


    • Do any risks necessitate other interventions?


    • What other things could we try?


    • What could happen if we delay one or two hours?

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    Pain Relievers

    Narcotic: Morphine, Fentanyl, Nubane, Stadol

    When/How Given

    • Early/active labor by IV or intramuscular injection. Fentanyl may also be given in spinal/epidural.
    Advantages
    • Not considered harmful to the mother/baby when given at the proper time and dosage.


    • Takes the "edge" off the pain.
    Possible Side Effects/Disadvantages
    • Makes some mothers sleepy.


    • May experience nausea (rare).


    • Mother may feel less in control.


    • Sometimes a decrease in strength and frequency of contractions occurs temporarily.


    • Depending on when given, Morphine may cause respiratory depression in the baby. If this occurs, the antidote Narcan can be administered and the side effects immediately reversed.


    • Morphine way cause the baby temporary difficulty with breastfeeding.

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    Regional Anesthesia (Epidural, Spinal & Intrathecal)

    There are several different types of regional anesthesia available: dilute local anesthetics, combination narcotics and local anesthetics, or more concentrated local anesthetics alone. Your physician/midwife and anesthesiologist will help you choose which type will best meet your needs, based on your stage and situation during labor and the amount of pain relief you require. Discuss the importance of being able to feel the pushing sensations and being able to work with your contractions with your physicians/midwife. Remember you will be assisted to manage your pain, so you will be able to maintain a sense of control.

    There are many options and ranges of pain relief, so you aren't faced with the choice of either unmanageable pain or no pain/no movement.

    Intrathecal (Narcotic and/or local anesthetic)

    When/How Given

    • Established labor for pain not relieved by other methods.


    • Needle inserted into central spinal fluid where medicine is injected and needle removed
    Advantages
    • Usually gives good pain relief.


    • Takes effect immediately.


    • Some mothers may be able to walk.


    • Does not alter pushing efforts.
    Possible Side Effects/Disadvantages
    • Itching.


    • Possible spinal headache (rare).


    • Limited time of duration.


    • Possible infection.


    Epidural Narcotic Only (Walking Epidural)

    When/How Given
    • Established labor for pain not relieved by other methods.


    • Needle inserted into epidural space and small catheter placed for later use (needle pulled out after catheter is inserted.
    Advantages
    • Usually gives good pain relief for early labor.


    • Some mothers may be able to walk.


    • Able to use catheter for local anesthetic later if needed.
    Possible Side Effects/Disadvantages
    • Itching.


    • Often restricts mobility.


    • Can become Spinal anesthesia if epidural catheter goes into the spinal fluid when inserted.


    • Intravascular injection.


    • Blood Pressure can drop within first 30 minutes after epidural is started, so frequent monitoring of blood pressure during that time.


    • Possible risk of infection.


    • May necessitate vacuum or forceps delivery due to decreased pushing ability.


    • May experience spinal headache postoperatively (rare).


    Local Anesthetic/Epidural

    When/How Given
    • As labor progresses, active/transition labor.


    • Usually given as a continuous infusion via a control pump.
    Advantages
    • Medication easily administered as labor advances.


    • Can shorten labor by allowing mother to relax.


    • Mother can usually push with assistance, may feel pressure


    • Medication can be turned down or off during second stage if necessary to assist with pushing sensation


    • Provides enough pain relief without sedation for Cesarean delivery; allows mother to remain awake during surgery


    • Total blockage of sensation yet mother stays conscious
    Possible Side Effects/Disadvantages
    • Often restricts mobility requiring bedrest during labor.


    • Can become spinal anesthesia if epidural catheter goes into the spinal fluid when inserted.


    • Intravascular injection.


    • Blood Pressure can drop within first 30 minutes after epidural is started, so frequent monitoring of blood pressure during that time.


    • Possible risk of infection.


    • May necessitate vacuum or forceps delivery due to decreased pushing efforts.


    Spinal Block

    When/How Given
    • May be given for Cesarean birth.


    • Medication is injected into spinal canal.
    Advantages
    • Effective immediately
    Possible Side Effects/Disadvantages
    • May experience spinal headache postoperatively (rare).


    • Itching.

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    Local Blocks

    (All local anesthetic-type drugs; such as Novacaine used by dentists.)

    Pudendal

    When/How Given

    • Given after 10 centimeters but before delivery.


    • Medication is injected into the nerves inside the vagina.
    Advantages
    • Local numbness for use for forceps, vacuum extractor or for repair of vaginal tears.
    Possible Side Effects/Disadvantages
    • Effective only 80 percent of the time


    • Short-acting


    Local

    When/How Given
    • Medication is injected into the perineum/skin immediately before or after delivery
    Advantages
    • Local numbness for performing episiotomy and suturing episiotomy or laceration
    Possible Side Effects/Disadvantages
    • Allergic reaction (rare)


    • Short-acting

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    Cesarean Section Medications

    General Anesthesia

    When/How Given

    • Given for an emergency Cesarean, unless functioning epidural is in place
    Advantages
    • Complete pain relief until awake


    • Local numbness for performing episiotomy and for suturing episiotomy or laceration
    Possible Side Effects/Disadvantages
    • Baby receives the medication. May be sleepy and possibly have some transient respiratory depression


    • Mother unconscious


    • Rare complications such as cardiac or respiratory depression or aspiration of vomitus could occur


    • May cause nausea postoperatively


    • Requires narcotic pain medication after surgery. For example, Demerol or Morphine by injection of Patient Control Analgesia (PCA) pump


    Epidural

    When/How Given
    • May be used for Cesarean section. Larger doses of local anesthetic used to numb entire abdomen and legs through epidural catheter
    Advantages
    • Complete pain relief


    • Mother stays awake


    • Narcotic may be given into epidural space for post-operative pain control
    Possible Side Effects/Disadvantages
    • May feel pressure during procedure


    • Rare complication of injection into central spinal fluid or epidural vein


    • Possible increase in mother's and/or infant's temperature


    Spinal

    When/How Given
    • May be used for Cesarean delivery. Needle inserted into central spinal fluid and local anesthetic with/without narcotic injected
    Advantages
    • Complete and immediate pain relief


    • Mother stays awake


    • Good post-operative pain control if narcotic given
    Possible Side Effects/Disadvantages
    • May feel pressure during procedure as with epidural


    • Rare complication of cardiac or respiratory depression

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    Labor Augmentation/Induction

    Prostaglandin Gel or insert (Cervidil)

    When/How Given

    • Administered vaginally prior to induction of labor
    Advantages
    • Increases cervical elasticity and softens/ripens cervix
    Possible Side Effects/Disadvantages
    • Requires fetal monitoring for 1 to 2 hours after insertion


    • Cervidil insert requires monitoring every two hours for 30 minutes


    • Risk for sustained, tetanic contractions


    Misoprostyl (Cytotec)

    Advantages
    • May stimulate contractions and enhance effects of Pitocin if used


    Oxytocin (Pitocin)

    When/How Given
    • Used for induction of labor or augmentation during labor


    • Administered through intravenous pump
    Advantages
    • Induces (begins) labor contractions


    • Augments (increases) strength and frequency of ongoing labor contractions
    Possible Side Effects/Disadvantages
    • Requires careful monitoring


    • May increase frequency, strength and pain of contractions

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    Postpartum Medications

    Oxytocin (Pitocin)

    When/How Given

    • Given after delivery of the placenta usually in IV bag or injection if no IV present
    Advantages
    • Injection or one IV bag usually given after delivery to ensure that the uterus remains contracted and may prevent excessive bleeding


    • Causes the uterus to contract
    Possible Side Effects/Disadvantages
    • Cramping


    Methergine

    When/How Given
    • Given after delivery either orally or by injection. Often series of six pills
    Advantages
    • Given when excessive vaginal bleeding occurs


    • Stronger than Oxytocin
    Possible Side Effects/Disadvantages
    • Cramping and nausea


    • Contraindicated if high blood pressure problematic


    Hemabate

    When/How Given
    • Given for excess bleeding that is not stopped by Pitocin and/or Methergine

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