Labor anelgesia

[StCEMT]

So I actually asked this question to a medic in passing that was an adjunct for our class back when I was still in medic school and the response I got was akin to asking if I could poke the baby in the eye. However, I came across this article discussing exactly what I had asked about and it doesn't seem like my question was actually all that unreasonable.

The question was about the use of Ketamine to help try to dull some of the pain from birthing a tiny human; that is one pain I am very empathetic towards. I realize it is entirely dependent on the situation, but assuming there is an opportunity to start an IV and set up the Ketamine, why shouldn't we? In this sample at least, it was a safe and effective option. This would probably be walking a line and I'd be leaving it up to the receiving doc, but I have no problem calling for something like this.

I ask because we actually get a fair amount of maternal calls where I work, whether they be hospital to hospital or scene calls and I have already very narrowly avoided walking in on a birth not too long ago.

Obligatory link. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3950455/

 

[EpiEMS]

Why not NO2? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3594866/

I mean, sadly, not enough services have it. But, of course, it would be awfully helpful.


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[StCEMT]

Why not NO2? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3594866/

I mean, sadly, not enough services have it. But, of course, it would be awfully helpful.


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I'd be all for it. Like you said though, availability is an issue. I have ketamine and decently flexible use of it per protocol. I don't think I have even seen NO2.

 

[TrueNorthMedic]

We use nitrous oxide all the time for patients in labour, and I find it to be very effective for most people. You really have to explain it well and get them to use it properly though. If they take full tidal volume breaths and hold each breath in for a couple of seconds then it works the best, from what I've seen.
Doesn't take the pain away completely but makes it tolerable. Another good thing is the short duration of action, stop using it for a few minutes, and it's pretty much gone from their system.

 

[GMCmedic]

Im passing this on to my Medical director. I like it

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[Carlos Danger]

No doubt that ketamine is effective for labor pain, but it is a pretty dirty drug. In small doses like the ones used in this study the side effects won't be a problem, but in larger or repeated doses they may be.

In early stages of labor, when IV analgesics are safe to use fairly liberally, the pain of contractions is usually quite tolerable, and IV analgesia really shouldn't be required. In late stages when the pain gets worse, the conundrum is that small doses won't cut it, but now that you are getting closer to delivery you have to be very careful with IV analgesics.

Nalbuphine works pretty well for labor pain. Probably a better choice than ketamine.

 

[EpiEMS]

@Remi, do you use nitrous/have you seen nitrous used?


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[StCEMT]

I know that article touched on some side effects, but are there any others you are thinking of in this case, specifically in the later stage? I'm really probably just going to give one dose anyway just due to circumstances.

I know a lower dose is not likely to make the pain go away, but realistically my goal would just to be take some of the edge off. Kinda the same situation as NO2. Maybe not the best tool for the job, but the best that I have so long as it is a safe option.

 

[Carlos Danger]

@Remi, do you use nitrous/have you seen nitrous used?

I use nitrous all the time in the OR, never even saw it prehospital though. It is a great drug and I think more EMS systems should use it.

 

[Carlos Danger]

I know that article touched on some side effects, but are there any others you are thinking of in this case, specifically in the later stage?

Primarily general dysphoria / confusion, as well as potential for amnesia of the birth, which some new moms find very distressing.

Really, if you do a lot of labor transports, you should try to get Nubain added to your protocols.

 

[StCEMT]

Primarily general dysphoria / confusion, as well as potential for amnesia of the birth, which some new moms find very distressing.

Really, if you do a lot of labor transports, you should try to get Nubain added to your protocols.

Ok, those make sense.

I don't know how many we actually do. The code (06) just says maternal case. That could be just a few weeks to full term pregnancies and a transfer or a 911. Some days I don't hear any and some days I hear a few go out. I seem to get about one pregnant patient a month or so.

Nitrous would be interesting to have and if I were to ask about anything, probably more likely. They are pretty tight with how much they give us, although we get generous use of what we have. Our clinical education guy had to fight just to get us nasal end tidal, Nubain would likely get shot down.

 

[GMCmedic]

Im passing this on to my Medical director. I like it

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I thought about this more last night and decided to take a deeper look at N2O. So far I like what I see and I can sell this to the medical director fairly easily.

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[NomadicMedic]

You might have difficulty finding N2O equipment for EMS.

I also think there is concern for abuse potential.

 

[GMCmedic]

You might have difficulty finding N2O equipment for EMS.

I also think there is concern for abuse potential.

Theyre anal about us checking tank pressure daily, though someone could always argue a leaky regulator.

We are contracted by our employer to do L&D/NICU/PICU transports. I think I can get L&D to buy us the initial equipment. Just have to make them think the equipment is for them lol

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[VentMonkey]

You might have difficulty finding N2O equipment for EMS.

I also think there is concern for abuse potential.

I thought it was much more prevalent in the prehospital setting in say, the 90's? (saw it used by "MEDIC" in NC on that old "paramedics" show), but was taken out of a lot of providers protocols for this very reason.

I remember learning about it as an NR drug during p school, and it being my favorite to learn because it was pretty basic to include max doses of:

"When the patient can't stop laughing."

 

[SandpitMedic]

Maybe after we increase some barriers to entry and get some more mature and professional folks around, we won't have the leading argument against NO2 being paramedics getting a quick high.

Abuse happens... and always will. Humans are not perfect. That said, it's a sad argument for a medical profession. (That's what we are, correct?)

When I worked in the Emirates we had it from BLS to ALS levels of care. Like another said, the regulators and volume were checked and recorded daily. The drug was great for patients, and I never had the urge to try it.

 

[EpiEMS]

They use similar things abroad without issue..."the green whistle", etc.


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[VentMonkey]

They use similar things abroad without issue..."the green whistle", etc.

Sandpit has a point about the fact that it should be a non-issue, and you're correct that Penthrox is very much common on ambulances in the UK. I don't know how, or why we're a different case.

I get increasing barriers, and educational standards, but is that literally all it takes? I wonder what the average age is for entry-level EMS providers across the pond?

 

[Carlos Danger]

I don't know exactly why N2o fell out of favor in American EMS. I'm guessing it was a combination of the factors mentioned above, but mostly I imagine it's just logistics and possibly cost. It is probably cheaper to stock an EMS unit with vials of fentanyl than with the equipment to administer N2o, and it's definitely easier to store and account for the IV drugs. Plus, narcs have the obvious advantage of not wearing off immediately when you stop administering them.

Don't get me wrong - I think N2o would be great to have in the field, and anyone who thinks they might be able to get their agency to get it should try to do so.

But back to labor pain specifically.......really, nalbuphine is a good option, guys. That's what the OB nurses use until we get a chance to place an epidural. It generally works pretty well and it's safe (though perhaps not ideal) to use even in later stages of labor if you really need to give some analgesia. The only time we really use N2o in OB anesthesia is when they are having a cesarean and the spinal is starting to wear off or is just patchy. Though they do use it routinely in Europe, from what I understand.

 

[GMCmedic]

We have a good group of medics at my current service. The youngest of us are in our early thirties, ranging up to 68 years old. On the tech side there are some in their early twenties but they have a good head on their shoulders. Almost all of us have been or are cops or firefighters also. Were all close as there are only about 36 of us field employees.

Not that any of this matters, i just dont see any of our current employees abusing N2O but the risk is there. Like has been mentioned, i dont think we should let that fear hold us back.

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