Page 138 Guide to Pain Management in Low-Resource Settings

126 Katarina Jankovic

is adequately treated, breastfeeding outcomes improve. breastfeeding because of negligible maternal plas-
Especially after cesarean birth or severe perineal trauma ma levels achieved. Extremely low doses of mor-
requiring repair, mothers should be encouraged to ad- phine are eff ective.
equately control their pain. • Continuous postcesarean epidural infusion may
be an eff ective form of pain relief that minimizes
Intravenous medications opioid exposure. A randomized study that com-
• Pethidine should be avoided because of reported pared spinal anesthesia for elective cesarean with
neonatal sedation when given to breastfeeding or without the use of postoperative extradural
mothers postpartum, in addition to the concerns continuous bupivacaine found that the continu-
of cyanosis, bradycardia, and risk of apnea, which ous group had lower pain scores and a higher vol-
have been noted with intrapartum administra- ume of milk fed to their infants.
tion. In general, if treatment of a lactating mother
• Th e administration of moderate to low doses of with an analgesic drug is considered necessary, the low-
intravenous (i.v.) or intramuscular (i.m.) mor- est eff ective maternal dose should be given. Moreover,
phine is preferred because transfer to breast milk infant exposure can be further reduced if breastfeeding
and oral bioavailability in the infant are lowest is avoided at times of peak drug concentration in milk.
with this agent. As breast milk has considerable nutritional, immuno-
• When patient-controlled i.v. analgesia (PCA) is logical, and other advantages over formula milk, the
chosen after cesarean section, morphine or fen- possible risks to the infant should always be carefully
tanyl is preferred to meperidine. weighed on an individual basis against the benefi ts of
• Although there are no data on the transfer of na- continuing breastfeeding.
lbuphine, butorphanol, or pentazocine into milk,
there have been numerous anecdotal reports of If I have no opioids available,
a psychotomimetic eff ect when these agents are
do I have any pharmacological
used in labor. Th ey may be suitable in individuals
with certain opioid allergies or other conditions options to relieve the discomfort

described in the preceding section on labor. of childbirth in my patients?
• Hydromorphone (approximately 7 to 11 times as
potent as morphine) is sometimes used for ex- A variety of diff erent drug classes are used in obstetrics
treme pain in a PCA, i.m., i.v., or orally. Following when regional techniques and opioids are not available.
a 2-mg intranasal dose, levels in milk were quite While neuroleptics (promethazine) and antihistamines
low, with a relative infant dose of about 0.67%. (hydroxyzine) are specifi cally indicated in nausea and
Th is correlates with about 2.2 μg/day via milk. vomiting, other drug classes have a direct eff ect on the
Th is dose is probably too low to aff ect a breast- distress of childbirth through their anxiolytic, sedative,
feeding infant, but this drug is a strong opioid, and dissociative activity. Above all, a single small dose
and some caution is recommended. of benzodiazepines may be used (mainly midazolam or
diazepam). In prodromal and early stages of childbirth,
Oral medications barbiturates (secobarbital or pentobarbital) may be a
• Hydrocodone and codeine have been used world- choice, and in experienced hands ketamine or S-ket-
wide in millions of breastfeeding mothers. Th is amine may be helpful. With “analgesic doses,” which are
history suggests that they are suitable choices, only a fraction of the anesthetic dose, cholinergic and
even though there are no data reporting their central nervous system eff ects are usually absent. Tram-
transfer into milk. Higher doses (10 mg hydroco- adol, which has some opioid-like eff ects but acts mostly
done) and frequent use may lead to some seda- by a unique mechanism, would be another alternative
tion in the infant. choice for analgesia. Tramadol is recommended at a dose
of 50–100 mg i.m. or i.v.; with effi cacy similar to that of
Epidural/spinal medications pethidine or morphine, it has fewer maternal side eff ects
• Single-dose opioid medications (e.g., neurax- and no neonatal depression. All of these drugs pass the
ial morphine) should have minimal eff ects on placental barrier and may induce sedation (“sloppy child”)