Thank you sooo much for sharing your precious time with me in this beautiful city. My primary goal is to make the best use of this valuable time together by presenting you with information that you will find useful and interesting and maybe a little entertaining as well.1

Why

this?

With such a wide range of anesthesia topics to choose from, you may be wondering why I specifically chose OB analgesia to speak about. (Pause) I would have to say that the topic kind of chose me. Let me explain2

First, a little background.Before I started working for Duke, I worked at a small, rural 100-bed community hospital in North Central NC. Even though it was less than an hour from both Duke and UNC hospitalsin many ways it seemed worlds apart. Our resources were limitedThe community that we served had the friendliest, most good-hearted people that you would ever want to meet!.... They were also some of the poorest in the state. Half of ALL the children (49.8% to be exact) living in the community, lives BELOW the poverty line. Every year we top the list for highest teen pregnancy rates in the state. As you might have already guessed, teenagers make up a large percentage of our OB populaton. It was here that I have done C-sections and labor epidurals for 12 & 13 year olds.

When I first started at that job, I was 1 of only 3 CRNAs. There was only 1 MDA and I was the only female on staff. The combined anesthesia experience of my colleagues equalled approximately 85 yearsI had barely 22 months! CLICK NEW GIRL PICTURE

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I vividly remember the 1st day that there was a scheduled c/s for my room. I searched everywhere for duramorph. When I finally asked one of my colleagues for help in finding it, he told me that we didnt have any. I was so confused. What was I suppose to do??! I had never done a c/s without adding morphine to the spinal. He explained how it was normally done with either plain bupivacaine or if I wanted to be fancy, I could also add a little fentanyl. The Obstetricians would then handle post-op pain management by writing for IV morphine PCA.

He went on to explain that the former medical director was opposed to duramorph as he didnt want to be responsible for pain management and be called in the middle of the night.Plus, it would require a change in policy in procedure for the L&D nurses r/t new monitoring requirements and the like.

I accepted his answer. I was NOT going to rock the boatat least for a very long while.

Fast forward 5 years. I had earned the respect of my colleagues and had even had a child of my own by then. The time had finally come time to address the issue of post-op pain management for c/ss.

Even so, it was not going to be easy! (next slide)4

When I mentioned to my new Director that my new years resolution was going to be FINALLY create the protocol for c/s post-op pain managementHis response was: Why do u want to do that for?!

The primary concern from my CRNA colleagues was that the itching would be worse than the pain.

And dont forget, I also had to get the OBs on board! That was not going to be easy either!

Two of the three OBs had absolutely no experience with it. The new OB that did, had a personal experience with duramorph. She recently had a c/s (at another facility) and told me that she wanted to scratch the skin off of her face.

I knew I had my work cut out for me... 5

I would have to come up with a solid game plan!

I actually started my project by doing an extensive literature review on opioid-induced pruritis... I knew... that my plan would instantly fail if I didnt have a way to deal with it.

Once I realized, I would be able to manage the pruritis, I went forward with the rest of the literature review on post-op pain management.

Long story short, I was able to present convincing evidence (to most) of the parties involved. And... after much collaboration, the orderset was launched in January of 2015 with much success. What a relief!6

So, That is the long story as to how I got involved with this topic. So then, when I was invited to speak at this conference.. it seemed like a good idea ...AT THE TIME!

I was so honored by the invitation that I immediately accepted!

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UPDATING the OUTDATED

So lets get started!!

I am going to break down this lecture into the following 3 major topics:

Labor analgesia options

Post-op pain management for c-sections

And how to best manage the side effects from our interventions.

I will also briefly touch upon a couple of the special populations that we see in all of of our practices, whether big of small: Wheth

they are the opioid dependent and morbidly obese moms.

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No Disclosures

Objectives:Pain management options for labor

Pain management options for C/S

Best management of side effects, i.e. pruritis

Common special populations

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I am NOT going to talk about non-pharm topics. Although nonpharm techniques have been beneficial to some moms, the evidence is limited. Some non-pharm techniques are better than placebo, some are not.

This mom looks very happy & satisfied with her experience.

(Click) I am not so sure about the little boy....

Obviously, we are here today to review pharmacologic options, so that will be our focus.11

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To the woman He said, I will greatly multiply your pain in childbirth; In pain you will give birth to children...-Genesis 3:16 AMP

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Queen Victoria16

Virginia Apgar18

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What we know

Physiology of labor pain: Increased catecholaminesincreased vasoconstriction to uterus

Hyperventilation causes left shift of oxyhemoglobin curve

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Shnider, S. M., et al (1983).

Maternal catecholamines decrease during labor after lumbar epidural anesthesia.

American journal of obstetrics and gynecology, 147(1), 13-15.

Lumbar epidural anesthesia during labor reduces maternal epinephrine levels, probably by eliminating the psychological and physical stress associated with painful uterine contractions or by denervating the adrenal medulla. Whatever the mechanism, reducing pain and activity of the sympathetic nervous system should increase uterine blood flow.21

Hyperventilationrespiratory alkalosisshifts the oxyhemoglobin curve to Lthereby increasing the affinity of oxygen for maternal hgbthereby ing off-loading of o2 to fetus. Hyperventilation also decreases uterine bloodflow 2nd utero-placental vasoconstriction.

Stats 61% of all women get epidurals.

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What we are also starting to learn

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List articles about PPdepression

Thangavelautham Suhitharan, T., et al (2016).

Investigating analgesic and psychological factors associated with risk of postpartum depression development: a casecontrol study.

Neuropsychiatric Disease and Treatment, 12, 1333.

The aim of this study was to investigate the role of peripartum analgesic and psychological factors that may be related to postpartum depression (PPD).METHODS: This case-control study was conducted in pregnant females who delivered at KK Women's and Children's Hospital from November 2010 to October 2013 and had postpartum psychological assessment. Demographic, medical, and postpartum psychological status assessments, intrapartum data including method of induction of labor, mode of labor analgesia, duration of first and second stages of labor, mode of delivery, and pain intensity on hospital admission and after delivery were collected. PPD was assessed using the Edinburgh Postnatal Depression Scale and clinical assessment by the psychiatrist.RESULTS: There were 62 cases of PPD and 417 controls after childbirth within 4-8 weeks. The odds of PPD was significantly lower (33 of 329 [10.0%]) in females who received epidural analgesia for labor compared with those who chose nonepidural analgesia (29 of 150 [19.3%]) ([odds ratio] 0.47 (0.27-0.8), P=0.0078). The multivariate analysis showed that absence of labor epidural analgesia, increasing age, family history of depression, history of depression, and previous history of PPD were independent risk factors for development of PPD.CONCLUSION: The absence of labor epidural analgesia remained as an independent risk factor for development of PPD when adjusted for psychiatric predictors of PPD such as history of depression or PPD and family history of depression.

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Ding, T. et al (2014):

Epidural labor analgesia is associated with a decreased risk of postpartum depression: a prospective cohort study.

Anesthesia & Analgesia, 119(2), 383-392.

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Severity of acute pain after childbirth, but not type of delivery, predicts persistent pain and postpartum depression

Eisenach, J.C., et al.Pain. 2008 Nov 15;140(1):87-94. doi: 10.1016/j.pain.2008.07.011. Epub 2008 Sep 24

Cesarean delivery rates continue to increase, and surgery is associated with chronic pain, often co-existing with depression. Also, acute pain in the days after surgery is a strong predictor of chronic pain. Here we tested if mode of delivery or acute pain played a role in persistent pain and depression after childbirth. In this multicenter, prospective, longitudinal cohort study, 1288 women hospitalized for cesarean or vaginal delivery were enrolled. Data were obtained from patient interviews and medical record review within 36 h postpartum, then via telephone interviews 8 weeks later to assess persistent pain and postpartum depressive symptoms. The impact of delivery mode on acute postpartum pain, persistent pain and depressive symptoms and their interrelationships was assessed using regression analysis with propensity adjustment. The prevalence of severe acute pain within 36 h postpartum was 10.9%, while persistent pain and depression at 8 weeks postpartum were 9.8% and 11.2%, respectively. Severity of acute postpartum pain, but not mode of delivery, was independently related to the risk of persistent postpartum pain and depression. Women with severe acute postpartum pain had a 2.5-fold increased risk of persistent pain and a 3.0-fold increased risk of postpartum depression compared to those with mild postpartum pain. In summary, cesarean delivery does not increase the risk of persistent pain and postpartum depression. In contrast, the severity of the acute pain response to childbirth predicts persistent morbidity, suggesting the need to more carefully address pain treatment in the days following childbirth.27

Effects of Persistent Childbirth Pain, Psychological and Pain Susceptibility on Postnatal Depressive Scores

Anesthesia & Analgesia: September 2016 - Volume 123 - Issue 3S_Suppl - p 254 doi: 10.1213/01.ane.0000492595.98883.93 E Poster discussion: Obstetric Du, W., et al.

Poster presentation from 3rd year Duke Medical Student (Singapore Campus) at the World Federation of Societies of Anesthesiologists Annual meeting in Hong Kong

Materials & Methods: We conducted a cohort study involving 200 healthy nulliparous term women who received epidural analgesia. Psychological vulnerability was assessed using the Perceived Stress Scale (PSS) and the Pain Catastrophizing Scale (PCS). A postnatal phone survey was conducted at 6 to 8 weeks to assess the presence of persistent childbirth pain and anxiety status, using pain questionnaire and Spielberger State Trait Anxiety Inventory (STAI) respectively. Postnatal depressive scores were measured using the Edinburgh Postnatal Depression Scale (EPDS). Generalized linear model for normal distribution was used to identify possible associations between pain, anxiety and stress with EPDS.Results: 138 women (69%) were included in the analysis. The incidence of PND (defined as EPDS score12) after 4 weeks postpartum, was 5.8%. Patients with persistent pain (>4 weeks postpartum) had significantly higher EPDS scores as compared to patients who had pain resolved by 4 weeks by a difference of 2.86 mean score (p=0.0145; 95% CI=0.59-5.34), and compared to patients who never had pain postpartum by a difference of 3.32 mean score (p=0.0207; 95% CI=0.51-6.13). Other factors that were positively associated with higher EDPS score include higher stress level (PSS) (p