INTRATHECAL NARCOTICS FOR OBSTETRIC ANALGESIA IN A COMMUNITY-HOSPITAL

OBJECTIVE: Our objective was to establish whether intrathecal narcotic s for obstetric analgesia offer an adequate and cost-effective alterna tive to epidural analgesia with minimal side effects in our small, sem irural community hospital with limited anesthesia coverage. STUDY DESI GN: Low-risk patients at greater than or equal to 35 gestational weeks in active labor were offered intrathecal narcotics. A retroactive cha rt review of every patient receiving an intrathecal injection was comp ared with a chart review of the next consecutive low-risk patient who did not receive an intrathecal narcotic. Age, parity, and status of la bor at the time of application were noted, as was the subsequent rate of labor and the type of delivery. Side effects such as changes in vit al signs, headache, vomiting, pruritis, urinary retention, and/or resp iratory depression were noted. All study patients received fentanyl, 2 5 to 35 mu g, plus 0.25 to 0.3 mg of preservative-free morphine combin ed with 6 to 8 mg of lidocaine. Within 15 minutes of delivery intraven ous nalbuphine (Nubain), 5 mg, and oral naltrexone, 12.5 mg, were admi nistered. Pain relief was recorded as excellent, satisfactory, or unsa tisfactory (requiring additional medication). RESULTS: During the 30-m onth review period, 90 patients (3% of total deliveries) received intr athecal narcotics. There were three sets of twins, for a total of 93 l ive births. Ten patients (11%) required primary cesarean section, and of the 83 vaginal births 35 (38%) were spontaneous, two (2%) required forceps deliveries, and 46 (49%) were delivered by vacuum extraction, which was significantly higher than the 28 (31%) for controls. The rat e of labor was not affected, with both groups requiring a similar rate of oxytocin (Pitocin) augmentation. Significantly more patients recei ving intrathecal narcotics experienced pruritus and urinary retention compared with controls. There was no incidence of respiratory depressi on. Eighty-four (93%) of the 90 patients reported excellent pain relie f, five patients had satisfactory relief lasting 2.5 to 6 hours, and o ne was unsatisfactory. CONCLUSIONS: In our hospital with limited anest hesia services intrathecal narcotics offer excellent labor pain relief with manageable side effects and without adverse obstetric outcome.