Can a patient with an existing epidural for adequate pain control receive Fentanyl (fentanyl) for pain management during manual removal of the placenta?

From the Guidelines

Intravenous fentanyl can be administered to a patient with an existing epidural when additional pain control is needed during manual removal of placenta, but careful monitoring is essential. A typical dose would be 50-100 mcg IV given slowly over 1-2 minutes, which can be repeated if necessary while monitoring vital signs 1. When combining IV fentanyl with epidural analgesia, the total opioid dose must be considered to avoid respiratory depression, hypotension, and excessive sedation. The procedure of manual placenta removal is intensely painful and often requires multimodal analgesia. Fentanyl works rapidly (within 1-2 minutes) to provide additional analgesia when the epidural alone is insufficient.

Some key considerations when administering fentanyl to patients with an existing epidural include:

• Monitoring oxygen saturation continuously and having naloxone readily available to reverse opioid effects if needed 1
• Ensuring resuscitation equipment is available
• Monitoring the patient for at least 1-2 hours after the last fentanyl dose due to the risk of delayed respiratory depression, particularly when combined with epidural opioids
• Considering the use of non-opioid scheduled multimodal analgesics, such as acetaminophen and ketorolac, to decrease the total amount of opioid provided to these patients 1
• Maintaining the patient's baseline dosage of opioids, as withholding these medications does not improve postpartum pain control and increases the risk of withdrawal 1

It is also important to note that patients with opioid use disorder (OUD) may require higher doses of opioid analgesic administered at shorter intervals to achieve adequate pain control, and that patient-controlled analgesia with a full agonist, such as fentanyl or hydromorphone, may be necessary for 24 hours 1.

From the Research

Administration of Fentanyl with Epidural

• The administration of fentanyl to a patient who already has an epidural for adequate pain control during manual removal of placenta is a complex issue, as it depends on various factors such as the dose and type of epidural, the patient's medical history, and the potential risks and benefits of fentanyl administration 2, 3.
• Studies have shown that epidural analgesia can minimize or totally avoid neonatal exposure to opioids and sedatives, which can be beneficial for the fetus, especially in conditions such as pregnancy-induced hypertension 2.
• However, the use of fentanyl in labor analgesia can cause neonatal respiratory depression, especially if the mother receives repeated doses of the opioid 2, 4.
• A study published in 2023 found that after a maternal epidural dose of fentanyl 245 µg, the predicted newborn plasma and brain extracellular fluid levels were below the toxicity thresholds, suggesting that fentanyl can be safely administered to patients with an epidural for pain control during labor 5.

Risks and Benefits

• The risks of administering fentanyl to a patient with an epidural include neonatal respiratory depression, which can be life-threatening if not properly managed 3, 4.
• However, fentanyl can also provide effective pain relief during labor, which can improve the patient's overall experience and reduce the risk of complications 2, 3.
• The benefits of fentanyl administration must be carefully weighed against the potential risks, and the patient's medical history and current condition must be taken into account when making a decision about fentanyl administration 2, 3.

Monitoring and Management

• Close monitoring of the patient and the fetus is essential when administering fentanyl to a patient with an epidural, as this can help identify any potential complications early on 3, 5.
• The use of naloxone, an opioid antagonist, may be necessary to reverse the effects of fentanyl in the event of neonatal respiratory depression 4.
• A study published in 2022 found that buprenorphine, a partial opioid agonist, can reduce fentanyl-induced respiratory depression in individuals with chronic opioid use, suggesting that this medication may be useful in managing fentanyl-related complications 6.