Taking the alternative route: Women's experience of intranasal fentanyl, subcutaneous fentanyl or intramuscular pethidine for labour analgesia.

OBJECTIVE: To compare women's experience of receiving either intranasal fentanyl, subcutaneous fentanyl or intramuscular pethidine for labour analgesia. DESIGN: A content analysis was undertaken as part of the third phase of a larger randomised controlled trial, using the per-protocol dataset to examine women's experiences of treatment received. Healthy women birthing at term, who received intranasal fentanyl (n=41), subcutaneous fentanyl (n=37) and/or intramuscular pethidine (n=38) for labour analgesia, were contacted at 6 weeks postpartum to complete a phone questionnaire. SETTING: A tertiary and regional maternity unit in South Australia. FINDINGS: Over 80% of women who received intranasal or subcutaneous fentanyl reported that they would use the treatment again compared to 44.8% of women who had received pethidine (self-administered intranasal fentanyl provided more expressive responses emphasising the route provided a strong sense of control and enablement. KEY CONCLUSIONS: Route of administration influenced the women's experience, more women who self-administered intranasal fentanyl reported positive emotional responses, with women reporting increased autonomy and satisfaction. Whereas, women who relied on the midwife to administer subcutaneous fentanyl or intramuscular pethidine, were more often focused on the physical effect of the drug. Pethidine was the least preferred option due to adverse effects. IMPLICATIONS FOR PRACTICE: For women requesting parenteral analgesia, fentanyl administered by less invasive routes offers women additional options that may better meet their emotional, cognitive and physical needs than the current practice of administering intramuscular pethidine.

The influence of intrapartum opioid use on breastfeeding experience at 6 weeks post partum: A secondary analysis.

OBJECTIVE: To examine breastfeeding experiences up to 6 weeks postpartum for mothers administered intranasal fentanyl, subcutaneous fentanyl or intramuscular pethidine for intrapartum analgesia. DESIGN: A secondary analysis was undertaken using the per-protocol dataset to examine the third phase of a larger randomised controlled trial. This phase of the study examined breastfeeding intention and experience from the first hour of birth to 6 weeks postpartum. Medical records were audited and women were contacted at 6 weeks postpartum to complete a telephone questionnaire. SETTING: Two maternity hospitals in South Australia. PARTICIPANTS: Healthy women birthing at term received intranasal fentanyl (n=37), subcutaneous fentanyl (n=37), or intramuscular pethidine (n=35). FINDINGS: While maternal characteristics and birth outcomes were comparable between groups, women who received either intranasal fentanyl or subcutaneous fentanyl experienced fewer difficulties in establishing breastfeeding by 6 weeks postpartum when compared to intramuscular pethidine (p<0.01). KEY CONCLUSIONS: Women who received fentanyl reported that their neonates had less difficulties establishing breastfeeding, compared to those who received pethidine. Therefore, for woman who intend to breastfeed, fentanyl should be the preferred opiate, for the relief of pain in labour. IMPLICATIONS FOR PRACTICE: When providing education to women in relation to intrapartum pain relief it is important to consider the potential influence on breastfeeding experience. This research provides evidence that fentanyl is a suitable alternative to pethidine for women requesting parenteral analgesia in labour.

Malawi women's knowledge and use of labour and birthing positions: A cross-sectional descriptive survey.

PROBLEM: Despite research evidence supporting use of upright birthing positions, most women give birth in supine position. Little is known about women's knowledge and use of labour and birthing positions. Specifically, there is a lack of evidence on Malawi women's knowledge and use of birthing positions, and this limits the possibility of improvement in childbirth practices. AIM: To assess women's knowledge and use of different positions during labour and birthing. METHODS: The study used a cross-sectional descriptive survey in a Malawi maternity unit where 373 low-risk postnatal women participated in face-to-face exit interviews, using a structured questionnaire. A descriptive analysis of the categorical variables was conducted to examine frequencies and percentages. FINDINGS: The majority of women knew about walking (66.4%) and lateral (60.6%) as labour positions, whereas 99.2% knew about the supine as a birthing position. Half of the women (50%) walked during labour and the majority (91.4%) gave birth whilst in supine position. Midwives were the main source of information on positions used during childbirth. DISCUSSION: Education about different birthing positions is needed for women who deliver at the maternity unit so that they can make informed decisions on their own options for childbirth. However, midwives must have the competence to encourage and assist women give birth in different positions, so professional development of midwives in childbirth positions is a priority. CONCLUSION: Childbirth education should include information on the various labour and birthing positions. Midwives should be equipped with appropriate skills to help women use different positions during childbirth.

Subcutaneous administration of fentanyl in childbirth: an observational study on the clinical effectiveness of fentanyl for mother and neonate.

OBJECTIVE: to explore the maternal and neonatal effects of fentanyl administered subcutaneously to women during labour. DESIGN: two methods were used: (1) A retrospective audit of the birth register and maternal and neonatal records for the period from January 2000 to December 2007. (2) A pilot study was also conducted on a convenience sample of women between July 2008 and October 2008. SETTING: this study was conducted within a maternity unit at a rural South Australian hospital where approximately 350 babies are birthed each year. PARTICIPANTS: audit participants included women who had uncomplicated pregnancies and birthed at term (37-42 weeks gestation). Women in the experimental group consisted of those who had utilised only subcutaneous fentanyl for pain relief (n=75), or nitrous oxide and oxygen prior to being administered subcutaneous fentanyl (n=196). Stratified random selection based on parity and age was used to determine the control group, which consisted of women who used no pharmacological pain relief (n=196). The pilot study involved a convenience sample of women (n=10) assessed to have an uncomplicated pregnancy and labour occurring at term (≥37 weeks gestation). MEASUREMENTS: audit variables examined included the women's age, parity, labour duration, mode of birth (spontaneous or assisted), analgesia used, total dosage, time administered prior to birth, time of birth, neonatal Apgar scores, time to establish breathing, naloxone use, days spent in hospital post-birth and breast-feeding outcomes upon discharge. The pilot study explored maternal effects assessed pre- and 30 minutes post-administration of subcutaneously administered fentanyl by observing pain scores, vital signs, sedation levels, nausea/vomiting scores and anti-emetic use. To assess possible adverse effects in the neonate Apgar scores, time to establish respiration, naloxone use, transfer to neonatal nursery and breast-feeding outcomes upon discharge were recorded. FINDINGS: women in the experimental groups were more likely to be induced, experienced a longer duration of labour and had an increased likelihood of an assisted vaginal birth. The average total dose of fentanyl administered was 250 µg. Neonatal outcomes were comparable between groups when examining Apgar scores <7 at 1 and 5 minutes and time to establish breathing. There was, however, a significant difference with naloxone administration between the groups. There was no significant difference between groups in hospital stay or breast-feeding on discharge. The pilot study identified a clinically significant reduction in pain scores for 78% of women following the administration of subcutaneous fentanyl, with the average pain score decreasing from 8.4 (±1.4) to 7.2 (±1.1) (paired t-test, p=0.017). Vital signs were not affected, no anti-emetics were required and all women remained alert with no sedation noted. KEY CONCLUSIONS: the audit identified fentanyl use was associated with a longer length of labour, but this may be explained by more women in the experimental groups requiring induction of labour than those in the control group. However, length of hospital stay, breast-feeding rates and neonatal outcomes were comparable amongst the three groups. Results of the pilot study are consistent with those of the audit in relation to the effects on mother and neonate. In addition, the pilot study begins to provide evidence that fentanyl is efficacious in providing pain relief. IMPLICATIONS FOR PRACTICE: results of this study are the first to explore the effects of fentanyl administered subcutaneously to women during labour. This method of analgesia offers women an additional choice of pain relief during childbirth and may be particularly beneficial in remote and rural settings where resources are often limited and access to specialist services difficult. Further research, however, is required to be able to generalise the outcomes and provide further data to support the clinical effectiveness of this route of administration of fentanyl.

Non-axial administration of fentanyl in childbirth: a review of the efficacy and safety of fentanyl for mother and neonate.

OBJECTIVE: to investigate the use of fentanyl for pain relief during childbirth administered by routes other than epidural or spinal (non-axial). In particular, aspects relating to the efficacy and safety of fentanyl for mother and neonate are explored. BACKGROUND: currently, pethidine is the most widely used intramuscular opioid for the relief of labour pain but has been shown to have numerous side-effects on the mother and neonate. An alternative opioid, fentanyl, has been shown to have fewer side-effects on both mother and neonate than pethidine. Therefore, its use during childbirth was examined in this literature review. REVIEW METHODS: a search of articles relating to the administration of fentanyl via non-axial routes was conducted using electronic databases, key journals and reference lists of selected research papers and reviews. RESULTS: only studies of IV administration were identified from the literature findings from showed that IV administered fentanyl appeared to be a safe, efficacious opioid when administered for pain relief in childbirth. Fentanyl is a short-acting analgesic causing less sedation and nausea in adults than pethidine. In addition, no long-term fetal or neonatal effects of fentanyl were identified, with normal neonatal neurological and adaptive capacities at two hours and 24 hours after birth supporting its safe use in childbirth. KEY CONCLUSION: in the studies identified, fentanyl was found to be efficacious, providing prompt analgesia with minimal side-effects to both mother and infant when administered intravenously (IV) during childbirth. In addition, no long-term fetal effects were found. RECOMMENDATIONS FOR FURTHER RESEARCH: there is a paucity of research relating to the maternal, fetal and neonatal effects of non-axial administered fentanyl other than that of IV. Further research should explore alternate routes of administration such as subcutaneous, sublingual and nasal which are less invasive and can be administered by midwives. IMPLICATION FOR PRACTICE: in confirming the safe use of non-axial administration of fentanyl during childbirth, benefits include midwives being able to offer women an alternative option for pain relief. Alternative routes, such as subcutaneous, can be managed by midwives through a standing order, potentially reducing the need for additional resources. In particular, this will benefit midwifery practice in rural and remote settings where resources and access to specialised services are limited.