What are the alternative analgesia (pain relief) options, excluding epidural and spinal anesthesia, for labor, delivery, and postpartum, and what are their effects on the neonate (newborn) and lactation (breastfeeding)?

From the Guidelines

Non-neuraxial analgesia options for labor, delivery, and postpartum pain management include systemic opioids, nitrous oxide, non-pharmacological methods, NSAIDs, and local anesthetic techniques, with the goal of minimizing side effects for both mother and baby. When considering analgesia options, it is essential to prioritize the safety and well-being of both the mother and the baby. Some key points to consider include:

• Systemic opioids like morphine, fentanyl, and remifentanil can provide moderate pain relief but may cause maternal respiratory depression, nausea, and sedation, and can cross the placenta, potentially causing neonatal respiratory depression and decreased alertness, which may temporarily impact early breastfeeding 1.
• Nitrous oxide (50:50 with oxygen) offers mild to moderate pain relief with minimal fetal effects but can cause maternal dizziness and nausea.
• Non-pharmacological methods, such as hydrotherapy, TENS units, acupuncture, hypnosis, and relaxation techniques, have no adverse effects on the baby or breastfeeding.
• For postpartum pain, NSAIDs (ibuprofen 400-600mg every 6 hours) and acetaminophen (1000mg every 6 hours) are effective and safe for breastfeeding mothers, as they have been shown to be compatible with breastfeeding, with minimal amounts detected in breast milk 1.
• Local anesthetic techniques, like pudendal nerve blocks (10-20ml of 1% lidocaine) for delivery and perineal infiltration for episiotomy repair, provide targeted pain relief without systemic effects.
• For severe postpartum pain, limited opioid use (oxycodone 5-10mg every 4-6 hours) may be necessary but should be minimized due to potential infant sedation through breast milk, and women should be advised to observe their infant for signs of abnormal drowsiness and respiratory depression 1. It is also important to consider the benefits of multimodal analgesia, which combines several methods to provide the best pain control while minimizing side effects for both mother and baby, as recommended in the most recent guidelines 1. Multimodal approaches can include a combination of basic analgesics, such as paracetamol and NSAIDs, with local or regional analgesic techniques, and may also incorporate non-pharmacological methods and analgesic adjuncts, such as listening to music via headphones and transcutaneous electrical nerve stimulation. Ultimately, the goal is to provide effective pain management while prioritizing the safety and well-being of both the mother and the baby.

From the FDA Drug Label

In humans, the frequency of congenital anomalies have been reported to be no greater than expected among the children of 70 women who were treated with morphine during the first four months of pregnancy or in 448 women treated with morphine anytime during pregnancy Morphine readily passes into the fetal circulation and may result in respiratory depression and psycho-physiologic effects in neonates. Low levels of morphine sulfate injection have been detected in maternal milk. Premature Closure of Fetal Ductus Arteriosus: Avoid use of NSAIDs in women at about 30 weeks gestation and later in pregnancy, because NSAIDs, including ibuprofen tablets, can cause premature closure of the fetal ductus arteriosus Oligohydramnios/Neonatal Renal Impairment: If an NSAID is necessary at about 20 weeks gestation or later in pregnancy, limit the use to the lowest effective dose and shortest duration possible.

Analgesia options other than epidural and spinal for labour, delivery, and postpartum include:

• Morphine (IV): can be used for pain relief during labor, but may cause respiratory depression and psycho-physiologic effects in neonates 2
• Ibuprofen (PO): can be used for pain relief during labor, but should be avoided at about 30 weeks gestation and later in pregnancy due to the risk of premature closure of the fetal ductus arteriosus, and used with caution at about 20 weeks gestation or later in pregnancy due to the risk of oligohydramnios and neonatal renal impairment 3

Effects on the baby:

• Morphine: may cause respiratory depression and psycho-physiologic effects in neonates 2
• Ibuprofen: may cause premature closure of the fetal ductus arteriosus and oligohydramnios, leading to neonatal renal impairment 3

Effects on breastfeeding:

• Morphine: low levels of morphine sulfate injection have been detected in maternal milk, and may cause respiratory depression, sedation, and possibly withdrawal symptoms in nursing infants 2
• Ibuprofen: it is not known whether this drug is excreted in human milk, but due to the potential for serious adverse reactions in nursing infants, a decision should be made whether to discontinue nursing or discontinue the drug 3

From the Research

Analgesia Options for Labour, Delivery, and Postpartum

Other than epidural and spinal analgesia, there are several options available for pain management during labour, delivery, and postpartum. These include:

• Systemic pharmacologic agents, such as opioids (e.g., meperidine, nalbuphine, tramadol, butorphanol, morphine, and remifentanil) and non-opioid agents (e.g., parenteral acetaminophen and nonsteroidal anti-inflammatory drugs) 4
• Nonpharmacologic methods, such as relaxation techniques (e.g., yoga, hypnosis, and music), manual techniques (e.g., massage, reflexology, and shiatsu), acupuncture, birthing ball, and transcutaneous electrical nerve stimulation 4
• Inhalational analgesia, such as nitrous oxide 5, 6
• Immersion in water, which may improve management of labour pain with few adverse effects 6
• Local anaesthetic nerve blocks or non-opioid drugs, which may relieve pain and improve satisfaction with pain relief 6

Effects on the Baby

The effects of these analgesia options on the baby are:

• Opioids may cause respiratory depression in the newborn, but this can be treated with naloxone 5
• Epidural analgesia may be associated with a lower risk of respiratory depression in the newborn compared to opioid analgesia 5
• There is no clear difference in neonatal outcomes, such as admission to neonatal intensive care unit or Apgar score, between epidural and non-epidural analgesia 5
• The impact of maternal opioid administration during labour on subsequent neonatal behaviour and breastfeeding is not well studied, with only two out of 57 trials of opioids reporting breastfeeding as an outcome 6

Effects on Breastfeeding

The effects of these analgesia options on breastfeeding are:

• Epidural analgesia may not affect breastfeeding, with some studies suggesting that it may even facilitate breastfeeding by reducing pain and stress during labour 7
• Opioids may affect breastfeeding, but the evidence is limited, and more studies are needed to explore the potential impact of different opioids and dosing regimens on breastfeeding 6, 8