question: How can pregnant women do Fentanyl (epidural) during labor without harming the baby?
comment: Because it's a local anesthetic, not ingested. Same as when you go to the dentist and get a shot of Novocaine. It numbs the area being worked on, but you don't get high. There's no connection between the mother's spine and the baby to deliver the Fentanyl through. Spilling a glass of Vodka on a pregnant woman doesn't effect the baby, Drinking that glass will.
passages: One study concluded that women whose epidural infusions contained fentanyl were less likely to fully breastfeed their infant in the few days after birth and more likely to stop breastfeeding in the first 24 weeks. However, this study has been criticized for several reasons, one of which is that the original patient records were not examined in this study, and so many of the epidural infusions were assumed to contain fentanyl when almost certainly they would not have. In addition, all those who had received epidural infusions in this study had also received systemic pethidine, which would be much more likely to be the cause of any effect on breastfeeding due to the higher amounts of medication used via that route. If this were the case, then early epidural analgesia which avoided the need for pethidine would be expected to improve breastfeeding outcomes rather than worsen them. Traditional epidural for labor relieves pain reliably only during first stage of labor (uterine contractions until cervix is fully open). It does not relieve pain as reliably during the second stage of labor (passage of the fetus through the vagina).
   CSE in labouring women is associated with more pruritus if fentanyl (25μg) is given intrathecally, than low-dose epidural analgesia. However, no difference has been found in the incidence of post dural puncture headache, requirement for epidural blood patch or maternal hypotension.
  
  The COMET Study, published in The Lancet in 2001 (vol358, No9275 p19-23) showed that a combined spinal epidural in labor may speed up the labor process by a few minutes.
   Fentanyl is sometimes given intrathecally as part of spinal anaesthesia or epidurally for epidural anaesthesia and analgesia. Because of fentanyl's high lipid solubility, its effects are more localized than morphine, and some clinicians prefer to use morphine to get a wider spread of analgesia. However, it's widely used in obstetrical anesthesia because of its short time to action peak (about 5 min), the rapid termination of its effect after a single dose, and the occurrence of relative cardiovascular stability. In obstetrics, the dose must be closely regulated in order to prevent large amounts of transfer from mother to fetus. At high doses, the drug may act on the fetus to cause postnatal respiratory distress.
   Care must be taken to guard against the application of external heat sources (such as direct sunlight, heating pads, etc.) which in certain circumstances can trigger the release of too much medication and cause life-threatening complications.
   Epidural analgesia provides rapid pain relief in most cases. It is more effective than opioids and other common modalities of analgesia in childbirth. Epidurals during childbirth are the most commonly used anesthesia in this situation. The medication concentrations and doses are kept low to decrease the side effects to both mother and baby. When in labor the mother does not usually feel pain after an epidural but they do still feel the pressure. Women are able to bear down and push with contractions. Epidural clonidine is rarely used but has been extensively studied for management of analgesia during labor. Epidural analgesia is a relatively safe method of relieving pain in labor. In a 2018 Cochrane review which included 52 randomized controlled studies involving more than 11,000 women, where most studies compared epidural analgesia with opiates, epidural analgesia in childbirth was associated with the following advantages and disadvantages:
   In the UK, the National Institute for Health and Care Excellence (September 2007) specifically recommends CSE for women who require rapid onset of analgesia in labour. It further recommends the use of bupivacaine and fentanyl to establish the block.
  
  Cautions and contraindications are very similar to those for epidural anaesthesia.
   Epidural analgesia does increase the duration of the second stage of labour by 15 to 30 minutes and may increase the rate of instrument-assisted vaginal deliveries as well as that of oxytocin administration. Some people have also been concerned about whether the use of epidural analgesia in early labour increases the risk of cesarean delivery. Three randomized, controlled trials showed that early initiation of epidural analgesia (cervical dilatation, 4 cm) does not increase the rate of cesarean delivery among women with spontaneous or induced labour, as compared with early initiation of analgesia with parenteral opioids.
  
  Section::::Anatomy.
   Its use as an analgesic during labour is generally advised against due to its long onset of action (1 hour). The ratio of the mean concentration of the drug in the fetus compared to that of the mother when it is given intramuscularly for labour pains has been estimated to be 1:94.
  
  Section::::Contraindications.:Children.
   Medicine administered via epidural can cross the placenta and enter the bloodstream of the fetus. Epidural analgesia has no statistically significant impact on the risk of caesarean section, and does not appear to have an immediate effect on neonatal status as determined by Apgar scores.
  
  Section::::Management.:Augmentation.
   BULLET::::- "epidural anaesthesia and analgesia significantly slows the second stage of labour". The following are a few plausible hypotheses for this phenomenon:
  
  BULLET::::- The release of oxytocin, which stimulates the uterine contractions that are needed to move the child out through the vagina, may be decreased with epidural anaesthesia or analgesia due to factors involving the reduction of stress, such as:
  
  BULLET::::- Epidural analgesia may reduce the endocrine stress response to pain
  
  BULLET::::- Diminished release of epinephrine from the adrenal medulla slows the release of oxytocin
   Different measures for pain control have varying degrees of success and side effects to the woman and her baby. In some countries of Europe, doctors commonly prescribe inhaled nitrous oxide gas for pain control, especially as 53% nitrous oxide, 47% oxygen, known as Entonox; in the UK, midwives may use this gas without a doctor's prescription. Opioids such as fentanyl may be used, but if given too close to birth there is a risk of respiratory depression in the infant.
   In addition to blocking the nerves which carry pain, local anaesthetic drugs in the epidural space will block other types of nerves as well, in a dose-dependent manner. Depending on the drug and dose used, the effects may last only a few minutes or up to several hours. Epidural analgesia typically involves using the opiates fentanyl or sufentanil, with bupivacaine or one of its congeners. Fentanyl is a powerful opioid with a potency 80 times that of morphine and side effects common to the opiate class. Sufentanil is another opiate, 5 to 10 times more potent than Fentanyl. Bupivacaine is markedly toxic if inadvertently given intravenously, causing excitation, nervousness, tingling around the mouth, tinnitus, tremor, dizziness, blurred vision, or seizures, followed by central nervous system depression: drowsiness, loss of consciousness, respiratory depression and apnea. Bupivacaine has caused several deaths by cardiac arrest when epidural anaesthetic has been accidentally inserted into a vein instead of the epidural space.
   Practitioners who make frequent use of the CSE technique for labour analgesia may note unexpected benefits. One example is in the event that the epidural catheter is unintentionally placed into a blood vessel. This requires removal of the catheter and its replacement. With the traditional technique of epidural placement, the patient continues in pain without relief. If the CSE technique has been used, the intrathecal injection of fentanyl results in 60 to 90 minutes of good pain relief. This creates a more pleasant environment in which to replace the errant catheter with a properly sited one.
  
  Section::::Insertion technique.
   However, the review found no difference in overall Caesarean delivery rates, nor were there effects on the baby soon after birth. Also, the occurrence of long-term backache was no different whether an epidural was or was not used.
  
  Though complications are rare, some women and their babies will experience them. Some side effects for the mother include headaches, dizziness, difficulty breathing and seizures. The child may experience slowed heartbeat, temperature regulation issues and there could be high levels of drugs in the child's system from the epidural.
   The bioavailability of intranasal fentanyl is about 70–90%, but with some imprecision due to clotted nostrils, pharyngeal swallow and incorrect administration. For both emergency and palliative use, intranasal fentanyl is available in doses of 50, 100, and 200 µg. In emergency medicine, safe administration of intranasal fentanyl with a low rate of side effects and a promising pain reducing effect was demonstrated in a prospective observational study in about 900 out-of-hospital patients.
  
  In children, intranasal fentanyl is useful for the treatment of moderate and severe pain and is well tolerated.
  
  Section::::Medical uses.:Sublingual.
   Some routes of administration such as nasal sprays and inhalers generally result in faster onset of high blood levels, which can provide more immediate analgesia but also more severe side effects, especially in overdose. The much higher cost of some of these appliances may not be justified by marginal benefit compared with buccal or oral options. Intranasal fentanyl appears to be as equally effective as IV morphine and superior to intramuscular morphine for management of acute hospital pain.
   Although movement is possible, walking may not be if the medication affects motor function. An epidural can lower blood pressure, which can slow your baby's heartbeat. Fluids given through IV are given to lower this risk. Fluids can cause shivering. But women in labor often shiver with or without an epidural. If the covering of the spinal cord is punctured by the catheter, a bad headache may develop. Treatment can help the headache. An epidural can cause a backache that can occur for a few days after labor. An epidural can prolong the first and second stages of labor. If given late in labor or if too much medicine is used, it might be hard to push when the time comes. An epidural increases risk of assisted vaginal delivery.
   Amide-linked local anesthetic agents, such as lidocaine and bupivacaine, can become "trapped" in their ionized forms on the fetal side of the placenta, so their net transfer across the placenta is increased. An ester-linked local anesthetic agent, such as 2-chloroprocaine, is rapidly metabolized, and placental transfer is limited. Since the metabolism of 2-chloroprocaine by fetal plasma is slower than in maternal plasma, the potential for ion trapping exists. Fetal pH is slightly lower than maternal (7.32 to 7.38), thus most unionized drugs are "ion trapped" to a degree, even in a healthy fetus. Chloroprocaine (pKa 8.7) is the drug of choice for epidural analgesia and a decompensating fetus, because it does not participate in ion trapping. Placental transfer of 2-chloroprocaine is not influenced by fetal acidosis.
   Some caution that unnecessary use of fetal anesthetic may pose potential health risks to the mother. "In the context of abortion, fetal analgesia would be used solely for beneficence toward the fetus, assuming fetal pain exists. This interest must be considered in concert with maternal safety and fetal effectiveness of any proposed anesthetic or analgesic technique. For instance, general anesthesia increases abortion morbidity and mortality for women and substantially increases the cost of abortion. Although placental transfer of many opioids and sedative-hypnotics has been determined, the maternal dose required for fetal analgesia is unknown, as is the safety for women at such doses.
   BULLET::::- Prenatal methamphetamine exposure can cause premature birth and congenital abnormalities. Other investigations have revealed short-term neonatal outcomes to include small deficits in infant neurobehavioral function and growth restriction when compared to control infants. Also, prenatal methamphetamine use is believed to have long-term effects in terms of brain development, which may last for many years.
  
  BULLET::::- Cannabis in pregnancy is possibly associated with adverse effects on the child later in life.
  
  BULLET::::- Ionizing radiation
   Major side effects are rare. These include loss of vision, stroke, paralysis, or death when the corticosteroids are infected, as in a 2012 meningitis outbreak. Another study found an increased odds of developing epidural lipomatosis, independent of BMI or other factors.
  
  Section::::Technique.
   BULLET::::- Delayed onset of breastfeeding and shorter duration of breastfeeding: In a study looking at breastfeeding 2 days after epidural anaesthesia, epidural analgesia in combination with oxytocin infusion caused women to have significantly lower oxytocin and prolactin levels in response to the baby breastfeeding on day 2 postpartum, which means less milk is produced. In many women undergoing epidural analgesia during labour oxytocin is used to augment uterine contractions.
   Popular medical pain control in hospitals include the regional anesthetics epidurals (EDA), and spinal anaesthesia. Epidural analgesia is a generally safe and effective method of relieving pain in labour, but is associated with longer labour, more operative intervention (particularly instrument delivery), and increases in cost. However, a recent Cochrane review suggests that the new epidural techniques have no more effect on labour time and the used instruments. Generally, pain and stress hormones rise throughout labour for women without epidurals, while pain, fear, and stress hormones decrease upon administration of epidural analgesia, but rise again later.
   BULLET::::- There has been a good deal of concern, based on older observational studies, that women who have epidural analgesia during labour are more likely to require a cesarean delivery. However, the preponderance of evidence now supports the conclusion that the use of epidural analgesia during labour does not have a significant effect on rates of cesarean delivery. A Cochrane review analysis of over 11,000 women confirmed there was no increase in the rate of Caesarean delivery when epidural analgesia was employed.
   Nitrous oxide has the added benefit of limited side effects.  Some mothers may experience some dizziness, nausea, vomiting, or drowsiness, however, since dosing is determined by the patient, once these symptoms begin she can limit her use.  The gas takes effect quickly, but also lasts a short period of time so she must hold the mask to her face in order to benefit from the effects of analgesia. There is very little effect to the baby since it is quickly eliminated by the baby as soon as it begins breathing. Evidence does not suggest any clinically significant risk factors in the use of nitrous oxide gas as opposed to other methods of pain management both non-pharmacologic and pharmacologic in terms of Apgar or cord blood gas.  There is also limited evidence to determine whether there are any increased occupational risks to the healthcare provider associated with the use of nitrous oxide.
  
presuppositions: Epidural medication during labor may harm the baby.
corrections: The epidural is a local anesthetic and not ingested so there is no connection between the mother's spine and the baby.
raw_presuppositions: Epidural medication during labor may harm the baby. Epidural medication during labor may harm the baby.
raw_corrections: The epidural is a local anesthetic and not ingested so there is no connection between the mother's spine and the baby. The epidural is a local anesthetic and not ingested so there is no connection between the mother's spine and the baby.