Analgesia in Obstetrics

 

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Abstract

Background: An effective relief of labour pain has become an important part of obstetric medicine. Therefore regional nerve blocks, systemic analgesic and non-pharmacologic techniques are commonly used. This review article gives a summary of pathophysiology and anatomy of labour pain as well as advantages, disadvantages, risks and adverse reactions of analgesic techniques in newborns and parturients. Methods: We performed a selective literature search in Medline via PubMed using the search-terms “Analgesia” and “Obstetrics”. We also included the current guidelines of the German Society for Anesthesiology and Intensive Care Medicine. Results: PDA and CSE are safe techniques for the relief of labour pain if contraindications are excluded. The risk for instrumental delivery but not for caesarean section is increased under neuraxial analgesia. PDA and CSE should be performed in an early stage of labour using low doses of local anaesthetics if possible. It is not necessary to wait for a defined cervical dilatation before starting neuraxial analgesia. Anesthesiologists and obstetricians should inform patients as soon as possible before the situation of stress during labour. Systemic opioid analgesia is a possible alternative for neuraxial techniques. Because of possible side effects systemic remifentanil analgesia should only be performed under continuous monitoring. Several nonpharmacologic methods can also relieve labour pain, but results of studies about their effectiveness are inconsistent.

Zusammenfassung

Fragestellung: Eine effektive Schmerzbekämpfung ist zu einem wichtigen Bestandteil der geburtshilflichen Medizin geworden. Hierfür stehen Regionalanästhesietechniken, systemische Analgesieverfahren und nicht pharmakologische Methoden zur Verfügung. Die vorliegende Übersichtsarbeit gibt eine Zusammenfassung der anatomischen und (patho-)physiologischen Grundlagen des Geburtsschmerzes sowie der einsetzbaren Analgesieverfahren einschließlich ihrer Vorteile, Auswirkungen auf Mutter und Kind, Risiken und möglichen Komplikationen. Material und Methoden: Es erfolgte eine selektive Literaturrecherche zu den Stichwörtern Analgesie und Geburtshilfe in Medline via PubMed unter Einbeziehung der aktuellen Empfehlungen der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin. Ergebnisse: PDA und CSE sind unter Beachtung von Kontraindikationen sichere Verfahren zur Schmerzreduktion unter der Geburt. Die Sectio-Rate ist darunter im Gegensatz zur instrumentellen Entbindungsrate nicht erhöht. Ihr Einsatz sollte möglichst frühzeitig in der Eröffnungsphase und niedrigdosiert erfolgen. Das Abwarten einer definierten Muttermundsweite vor PDA-Anlage wird nicht empfohlen. Der Einsatz einer PDA sollte mit der Patientin schon im Vorfeld und nicht erst in der Stresssituation während der Wehen besprochen werden. Eine systemische Alternative zu PDA/CSE bietet die intravenöse Opioidanalgesie. Wegen möglicher Nebenwirkungen sollte eine systemische Analgesie mit Remifentanil nur unter kontinuierlichem Monitoring durchgeführt werden. Nicht medikamentöse Verfahren können ebenfalls Schmerzen unter der Geburt lindern. Studienergebnisse zu deren Wirksamkeit sind jedoch uneinheitlich.

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