Opioid Use and Labour
Question# 584
Why is active labour contraindicated for narcotics when narcotics are routinely given at hospital for labour, epidurals contain fentanyl and active labour is our common reference when asking patients their greatest pain experience.
Answer:
Labour is inherently painful, but fortunately, there are several nonpharmacologic and pharmacologic strategies available to help manage that pain. Since pain management is a highly personal experience, it's essential to involve the patient in discussions about analgesia, considering their values and preferences.
Nonpharmacologic methods don't eliminate labor pain but can significantly enhance the patient's ability to cope and maintain a sense of control throughout the birthing process (1).
Pharmacologically, acetaminophen is preferred over ibuprofen, though its effect is limited. The use of opioids, in active labour, however, should be avoided. Opioids can cause adverse effects such as nausea, vomiting, and sedation, potentially complicating the labour and delivery process.
More importantly, opioids cross the placenta, which can lead to decreased baseline fetal heart rate, neonatal respiratory depression, and lower Apgar scores - critical concerns given our limited ability to monitor fetal vitals. This could increase the risk of requiring neonatal resuscitation after birth.
Ultimately, if the patient is in active labour, the risks associated with opioid use in labor, outside of the hospital, generally outweigh any potential benefit and it's best to avoid.
In addition, a systematic review found that epidural analgesia is associated with less respiratory depression and lower rates of maternal nausea and vomiting compared to systemic opioid administration during labour. This is likely one of the reasons why it is preferred in the hospital setting.
Lastly, paramedics generally are not examining patients to see what stage of labour they are in. People experiencing intense contractions could be fully dilated and ready to push, or not dilated at all. Knowing how dilated they are can offer some indication of the timing of delivery. Administering a systemic opioid right before delivery could cause respiratory depression in a baby who is about to be cut off from their oxygen supply, which could seriously complicate the out-of-hospital course - another reason why you may see opioids given in the hospital setting.
For pregnant patients looking for analgesia, we suggest you read the following answer which describes our position:
https://www.rppeo.ca/paramedic-practice/medicask-about/medicask-answers-list/250-medical-directives/253-analgesia/1890-pain-management-in-pregnant-patients?highlight=WyJwcmVnbmFudCJd
Nonpharmacologic methods don't eliminate labor pain but can significantly enhance the patient's ability to cope and maintain a sense of control throughout the birthing process (1).
Pharmacologically, acetaminophen is preferred over ibuprofen, though its effect is limited. The use of opioids, in active labour, however, should be avoided. Opioids can cause adverse effects such as nausea, vomiting, and sedation, potentially complicating the labour and delivery process.
More importantly, opioids cross the placenta, which can lead to decreased baseline fetal heart rate, neonatal respiratory depression, and lower Apgar scores - critical concerns given our limited ability to monitor fetal vitals. This could increase the risk of requiring neonatal resuscitation after birth.
Ultimately, if the patient is in active labour, the risks associated with opioid use in labor, outside of the hospital, generally outweigh any potential benefit and it's best to avoid.
In addition, a systematic review found that epidural analgesia is associated with less respiratory depression and lower rates of maternal nausea and vomiting compared to systemic opioid administration during labour. This is likely one of the reasons why it is preferred in the hospital setting.
Lastly, paramedics generally are not examining patients to see what stage of labour they are in. People experiencing intense contractions could be fully dilated and ready to push, or not dilated at all. Knowing how dilated they are can offer some indication of the timing of delivery. Administering a systemic opioid right before delivery could cause respiratory depression in a baby who is about to be cut off from their oxygen supply, which could seriously complicate the out-of-hospital course - another reason why you may see opioids given in the hospital setting.
For pregnant patients looking for analgesia, we suggest you read the following answer which describes our position:
https://www.rppeo.ca/paramedic-practice/medicask-about/medicask-answers-list/250-medical-directives/253-analgesia/1890-pain-management-in-pregnant-patients?highlight=WyJwcmVnbmFudCJd
References
-Reale S. Pharmacologic management of pain during labor and delivery. UpToDate. (2024).
-Anim-Somuah, M., Smyth, R. M., Cyna, A. M., & Cuthbert, A. (2018). Epidural versus non-epidural or no analgesia for pain management in labour. The Cochrane database of systematic reviews, 5(5), CD000331.
-Anim-Somuah, M., Smyth, R. M., Cyna, A. M., & Cuthbert, A. (2018). Epidural versus non-epidural or no analgesia for pain management in labour. The Cochrane database of systematic reviews, 5(5), CD000331.