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Pharmacological Management of Pain in Obstetrics 127

in the neonate. Th erefore, if the use of these drugs is un- method. “Her Majesty is a model patient,” declared Dr
avoidable, postpartum observation of the neonate (for Snow. He refused to disclose any more details, despite
approximately 8–12 hours) is required. many importunate inquiries from the Queen’s loyal
subjects. Th e social elite in London soon followed the
What is the oldest analgesia Queen’s lead, adding further credibility to the use of
method still in use, and can it still anesthesia. Th e Lancet deplored the use of this “un-
be recommended? natural novelty for natural labor”; however, royal sanc-
tion helped make anesthesia respectable in midwifery
On Queen Victoria’s request, Dr. John Snow provided as well as surgery. Chloroform is no longer in use, but
for her eighth childbirth (Prince Leopold) the newly the method has withstood the test of time. Th e inhala-
developed chloroform anesthesia with an open-drop tion method of analgesia in labor now uses 50% nitrous

Table 2
Use of analgesics in pregnancy
Medication Risk Comments
Opioids and Opioid Agonists
Meperidine 1
Morphine 1 Neonatal narcotic withdrawal is seen in women using long-term opioids
Fentanyl 2
Hydrocodone 1 Almost all cause respiratory depression in the neonate when used near delivery
Oxycodone 2
Used for treatment of acute pain: nephrolithiasis, cholelithiasis, appendicitis, injury,
Propoxyphene 2 postoperative pain
Codeine 1
Hydromorphone 2
Methadone 3
Nonsteroidals
Associated with third-trimester (after 32 weeks) pregnancy complications: oligohy-
Diclofenac 4 dramnios, premature closure of ductus arteriosus
Etodolac 4
Ibuprofen 2/4
Both ibuprofen and indomethacin have been used for short courses before 32 weeks
Indomethacin 2/4 of gestation without harm; indomethacin is often used to arrest preterm labor
Ketoprofen 4
Ketorolac 4
Naproxen 4
Sulindac 4
Aspirin
Full-strength aspirin 4 Full-strength aspirin can cause constriction of the ductus arteriosus
Low-dose (baby) aspirin 1 Low-dose (baby) aspirin is safe throughout pregnancy
Salicylates
Acetaminophen 1 Widely used
Salicylate-Opioid Combinations
Acetaminophen-codeine 1 Widely used for treatment of acute pain
Acetaminophen-hydrocodone 1
Acetaminophen-oxycodone 1
Acetaminophen-propoxyphene 2
1 = Primary recommended agent
2 = Recommended if currently using or if their primary agent is contraindicated
3 = Limited data to support or prescribe use
4 = Not recommended.