Asian Journal of Medical Principles and Clinical Practice

The Effectiveness and Safety of Epidural Analgesia, Nitrous Oxide, or Patient-Controlled Analgesia (PCA) for Pain Management during Labor and Delivery: A Literature Review

Mona Abdelrahman Mohammed Mohammed

Fakih IVF Fertility Center- Abu Dhabi, UAE.

Eman Mohamed Ali Elshorbagy *

Al Dhannah Hospital, Al Dhannah City, Al Dhafra, Abu Dhabi, UAE.

Kholoud Ibrahim Ali Saleh El Shehawy

Fakih IVF Fertility Center- Abu Dhabi, UAE.

*Author to whom correspondence should be addressed.

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Abstract

Pain management during labor is an important aspect of obstetric care. Its purpose is to reduce maternal discomfort while ensuring the safety of the mother and newborn. Various pharmacological methods are used to treat labor pain, including epidural analgesia, nitrous oxide inhalation, and patient-controlled analgesia (PCA). Epidural analgesia involves administering local anesthetics and opioids into the epidural space, which effectively relieves pain by blocking nerve conduction. Numerous studies have demonstrated superior pain relief compared to other methods, resulting in high patient satisfaction. However, there are concerns about potential side effects such as hypotension, motor block, and prolonged labor. Additionally, the impact of epidural analgesia on the labor process and delivery method remains controversial. Similarly, nitrous oxide, also known as “nitrous oxide,” is an inhaled analgesic that is gaining popularity because of its rapid onset of action and short duration of action. It provides a non-invasive option to reduce pain during labor, allowing women to maintain mobility and control their breathing patterns. Although nitrous oxide is generally considered safe, its effectiveness varies from person to person, and some women report insufficient pain relief. In contrast, PCA allows patients to self-administer a predetermined dose of analgesic medication, that is usually an opioid, via an infusion pump or handheld device. This approach gives women a sense of autonomy and immediate pain relief without the need for repeated injections. Studies have shown that PCA can effectively relieve labor pain while minimizing opioid-related side effects such as respiratory depression and sedation. However, concerns have been raised about the potential for overdose and inadequate pain management if used inappropriately. The choice of pain management method during labor should be individualized based on the woman’s preferences, medical history, and obstetric circumstances. Although epidurals remain the gold standard for effective and lasting pain relief, they do have potential drawbacks. Nitrous oxide and her PCA offer a suitable alternative option for women seeking non-invasive or spontaneous pain relief strategies. This literature review evaluates the effectiveness and safety of these treatments in achieving optimal pain relief and maternal satisfaction while minimizing adverse outcomes.

Keywords: Labor pains, epidural anesthesia, nitrous oxide, patient-controlled anesthesia, pain management, delivery of fetus

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References

Labor S, Maguire S. The Pain of Labour. Rev Pain. 2008 Dec;2(2):15–9.

Smith A, Laflamme E, Komanecky C. Pain Management in Labor. Am Fam Physician. 2021 Mar 15;103(6):355–64.

Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, et al. Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev. 2012 Mar 14;2012(3):CD009234.

Beyable AA, Bayable SD, Ashebir YG. Pharmacologic and non-pharmacologic labor pain management techniques in a resource-limited setting: A systematic review. Ann Med Surg. 2022 Jan 31;74:103312.

Shiferaw A, Temesgen B, Alamirew NM, Wube T, worku Y. Utilization of labor pain management methods and associated factors among obstetric care givers at public health institutions of East Gojjam Zone, Amhara region, Ethiopia, 2020: A facility based cross – sectional study. BMC Pregnancy Childbirth. 2022 Nov 1;22:803.

Beigi NMA, Broumandfar K, Bahadoran P, Abedi HA. Women’s experience of pain during childbirth. Iran J Nurs Midwifery Res. 2010;15(2):77–82.

Aziato L, Acheampong AK, Umoar KL. Labour pain experiences and perceptions: a qualitative study among post-partum women in Ghana. BMC Pregnancy Childbirth. 2017 Feb 22;17:73.

Mwakawanga DL, Mselle LT, Chikwala VZ, Sirili N. Use of non-pharmacological methods in managing labour pain: experiences of nurse-midwives in two selected district hospitals in eastern Tanzania. BMC Pregnancy Childbirth. 2022 Apr 30;22:376.

Novikova N, Cluver C. Local anaesthetic nerve block for pain management in labour. Cochrane Database Syst Rev. 2012 Apr 18;2012(4):CD009200.

Anim‐Somuah M, Smyth RM, Cyna AM, Cuthbert A. Epidural versus non‐epidural or no analgesia for pain management in labour. Cochrane Database Syst Rev. 2018 May 21;2018(5):CD000331.

Avila Hernandez AN, Hendrix JM, Singh P. Epidural Anesthesia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Apr 8]. Available:http://www.ncbi.nlm.nih.gov/books/NBK542219/

Gerheuser F, Roth A. [Epidural anesthesia]. Anaesthesist. 2007 May;56(5):499–523; quiz 524–6.

Moraca RJ, Sheldon DG, Thirlby RC. The Role of Epidural Anesthesia and Analgesia in Surgical Practice. Ann Surg. 2003 Nov;238(5):663–73.

Pastino A, Lakra A. Patient-Controlled Analgesia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Apr 8]. Available:http://www.ncbi.nlm.nih.gov/books/NBK551610/

Motamed C. Clinical Update on Patient-Controlled Analgesia for Acute Postoperative Pain. Pharm J Pharm Educ Pract. 2022 Jan 27;10(1):22.

Silva M, Halpern SH. Epidural analgesia for labor: Current techniques. Local Reg Anesth. 2010 Dec 8;3:143–53.

Broughton K, Clark AG, Ray AP. Nitrous Oxide for Labor Analgesia: What We Know to Date. Ochsner J. 2020; 20(4):419–21.

Collins MR, Starr SA, Bishop JT, Baysinger CL. Nitrous Oxide for Labor Analgesia: Expanding Analgesic Options for Women in the United States. Rev Obstet Gynecol. 2012;5(3–4):e126–31.

Likis FE, Andrews JC, Collins MR, Lewis RM, Seroogy JJ, Starr SA, et al. Nitrous oxide for the management of labor pain: a systematic review. Anesth Analg. 2014 Jan;118(1):153–67.

Nodine PM, Collins MR, Wood CL, Anderson JL, Orlando BS, McNair BK, et al. Nitrous Oxide Use During Labor: Satisfaction, Adverse Effects, and Predictors of Conversion to Neuraxial Analgesia. J Midwifery Womens Health. 2020 May;65(3):335–41.

Froessler B, Malek M, Jila M, Parange A, Kelly T. The impact of withholding nitrous oxide in labour during the COVID‐19 pandemic on maternal and neonatal outcomes. Aust N Z J Obstet Gynaecol. 2022 Dec;62(6):910–4.

Colciago E, Fumagalli S, Inzis I, Borrelli SE, Nespoli A. Management of the second stage of labour in women with epidural analgesia: A qualitative study exploring Midwives’ experiences in Northern Italy. Midwifery. 2019 Nov 1;78:8–15.

Ismail S. Labor analgesia: An update on the effect of epidural analgesia on labor outcome. J Obstet Anaesth Crit Care. 2013 Dec;3(2):70.

Lindholm A, Hildingsson I. Women’s preferences and received pain relief in childbirth - A prospective longitudinal study in a northern region of Sweden. Sex Reprod Healthc Off J Swed Assoc Midwives. 2015 Jun;6(2):74–81.