Baillière's clinical obstetrics and gynaecology
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Women frequently use a mixture of analgesics to gain relief from the distress of childbirth and antenatally require information on their effectiveness and side-effects. One such example would be the reported long-term neonatal behavioural changes following systemic opioids such as pethidine. The most frequently reported maternal effects of epidural or spinal analgesia are prolonged symptoms of headache, backache and neurological sequelae. ⋯ Post-dural puncture headache is a recognized long-term complication of epidural nerve blockade. However, prospective studies have not confirmed any causal relationship between epidural analgesia and backache and neurological complications are five times more common after childbirth itself than after regional nerve blockade. Postpartum symptomatology describes significant morbidity in the community but its relationship to analgesia in labour is still to be proved.
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Baillieres Clin Obstet Gynaecol · Sep 1998
ReviewThe substance-abusing parturient: implications for analgesia and anaesthesia management.
Substance abuse remains a major problem in society, while substance abuse in pregnancy has emerged as a major health problem in the 1990s. Due to this trend, obstetricians, neonatologists and anaesthesiologists are encountering an increasing number of pregnant patients who use licit and illicit substances. ⋯ The following article reviews the various substances of abuse use by pregnant women and the implications of their use for analgesia and anaesthesia during labour and delivery. In conclusion, it is essential for physicians to identify the substance abusing parturient to optimize care of these patients and be prepared for the crises that may arise.
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Baillieres Clin Obstet Gynaecol · Sep 1998
ReviewNew epidural techniques for labour analgesia: patient-controlled epidural analgesia and combined spinal-epidural analgesia.
Epidural analgesia in labour aims to provide high-quality pain relief of rapid onset and prolonged duration, while minimizing both maternal side-effects, particularly impairment of mobility, and impact on the fetus or on the outcome of labour. In conjunction with pharmacological research on spinal analgesics (local anaesthetics, opioids and other drug classes), refinement of new or established drug delivery techniques has allowed progress toward more reliable and improved pain relief at all stages of labour and childbirth, reduced individual drug doses with reduction of unwanted effects and greater safety and enhancement of maternal satisfaction. Patient-controlled epidural analgesia in labour has been in use for almost a decade, although is only now at a stage where its role is well defined and utility can be increased. Combined spinal-epidural analgesia is a more recent refinement which appears to be extremely promising but awaits further investigation.
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For a number of reasons, bupivacaine has become the most frequently used local anaesthetic in obstetric anaesthesia, despite the fact that it has a narrower margin of safety than other local anaesthetics. In recent years, advances in technology have made single-isomer formulations of drugs available for clinical use. Generally speaking, the levo stereoisomer of amide local anaesthetic has a lower potential for systemic toxicity than the dextro form of the drug while retaining anaesthetic potency. ⋯ The other drug currently being investigated is levobupivacaine (Chirocaine, Chiroscience Ltd). Both drugs appear to be similar in efficacy to the currently used formulation of bupivacaine; however, they are more costly. Thus, cost-benefit analyses are required to define more clearly their future role in obstetric anaesthesia.
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Baillieres Clin Obstet Gynaecol · Sep 1998
ReviewPromising non-narcotic analgesic techniques for labour.
Epidural analgesia and spinal analgesia are the most effective techniques for relieving labour pain. Basically, local anaesthetics (i.e. bupivacaine) and opioids (i.e. fentanyl or sufentanil), especially when combined, produce excellent analgesia with minimal motor blockade. However, none of these agents is devoid of side-effects and analgesia remains sometimes imperfect, suggesting that new drugs would be welcome. ⋯ Other analgesic drugs are promising alternatives but are still at an experimental or very early clinical stage. Neostigmine and ketamine (without preservative) are not neurotoxic while midazolam neurotoxicity is still controversial. Intravenous remifentanil might prove useful when neuraxial analgesia is contraindicated.