Epidural analgesics have become a standard of care for pain management during labor and delivery. Many patients will receive an epidural containing an anesthetic such as ropivacaine or bupivacaine and an opioid analgesic such as fentanyl. These medications, when used in combination, have been shown to increase maternal satisfaction and decrease overall anesthetic consumption. However, the use of opioids in epidurals raises its own set of problems. There are risks to both mom and the neonate when opioids are used for pain management. In some healthcare facilities, there is a routine screening process to determine if drugs have been misused during the pregnancy. These facilities, at least in the United States, are required to report certain positive drug screens to the Department of Child Services (DCS) for investigation. This brings to light several questions to consider with respect to opioid use in the labor and delivery population. First, should we be using opioids in this population as a standard of care? Second, is there a need for screening of mothers and babies at time of delivery for common substances of abuse? Third, what is the most appropriate process for screening to limit false positive results and catch potential substance misuse?
Should we be using opioids in our labor and delivery patients?
Historically, opioids have been used for analgesia or pain relief in both pregnant and non-pregnant patients. They present a unique challenge in the pregnant population as they can result in fetal complications. These complications include increases in neonatal abstinence syndrome, rates of still born births, and fetal growth abnormalities when used over an extended period. In cases of acute usage, such as with epidural administration prior to delivery, there is a unique set of complications. These include increases in the rates of NICU admissions, respiratory distress in the infant, antibiotic usage, and maternal intrapartum fever. In the last couple of decades, there have been steady increases in opioid misuse and abuse within the United States. One medication that has seen increased rates of misuse in the community is fentanyl. Fentanyl is also a common component for epidural analgesia in labor and delivery departments across the US. In animal models, it has been shown that a 50 mcg intrathecally administered dose of fentanyl can reach the fetal arterial blood stream within 10 minutes. Therefore, within 10 minutes, there could be a positive urine drug screen in the infant after delivery. As mentioned previously, opioids are associated with adverse outcomes for the neonate, including NICU admission and antibiotic usage rates higher than those of babies not exposed to opioids. Along with these adverse outcomes, we can see increased rates of maternal intrapartum fever that increases rates of NICU admissions and encephalopathy. This sequalae associated with opioid containing epidurals raises the question of the need for fentanyl in these epidurals as a standard of care compared to limiting use to specific situations.
Is there a need for screening of mothers and babies at time of delivery for common substances of abuse?
A survey of 34 jurisdictions in the US identified that 6.6% of pregnant patients were using opioids, with 21.2% of those patients admitting to misuse of the medication. These rates of misuse in the community have prompted many facilities to screen mothers presenting for delivery for substance abuse. This process typically includes a urine drug screen performed on the mother prior to delivery.. In the US, any positive test result of an infant must be reported to DCS for further investigation. These test results may be positive for a variety of reasons, including the administration of epidural analgesics during labor and delivery. Once notified, DCS will perform their investigation, which can include a medical chart review or consultation with various hospital personnel to identify potential agents contributing to the test result. This investigation process can result in an extended stay in the hospital. If the result was erroneous or a false positive, the parent may take offense to any perceived accusations and seek legal action against the facility. Screening of patients prior to delivery can assist in the early identification of patients with neonatal abstinence syndrome who may require more intense post-natal care. While screening infants after delivery can assist in identifying potential cases requiring investigation through DCS, this puts physicians and healthcare teams in a dilemma, bringing to question the efficacy and safety of epidurally-administered opioids in this patient population.
What is the most appropriate process for screening to limit false positive results and catch potential substance misuse?
Facilities can identify their own testing protocols, but they must follow DCS guidance. For example, in Memphis, Tennessee, USA, there are two major facilities known for delivering babies. Facility A currently utilizes a universal screening policy for all patients presenting for delivery and for all infants born. This was a recent change from their prior practice using a survey to identify patients for drug screening. The facility found the previous practice did not accurately identify potential patients with substance use disorder. Facility B only screens infants if they have reason to suspect they have had exposure to a potentially illicit substance. They also do not screen infants whose mothers received an opioid containing epidural prior to delivery. In both situations, DCS guidance is still being followed, but when every mother-baby pair is tested, there is an increase in potential DCS-related investigations. While child safety is of extreme importance, the increased DCS investigations has the potential to increase workload on an already overburdened healthcare team. In the event of a false positive result, mothers may feel they are being accused of using drugs and seek legal action.
Epidurals containing opioids present a unique challenge to healthcare providers. While they provide improved maternal satisfaction rates and decreased overall usage of anesthetics, they may be associated with negative fetal outcomes. Neonates exposed to opioids can have increased NICU admission rates along with respiratory distress and increased antibiotic usage. Opioids are also associated with a potential increase in maternal intrapartum fever rates which in turn lead to increased NICU admissions and encephalopathy of the infant. In the US, DCS investigations can be time consuming and directly impact the cost of care for patients. There is also a potential for patients to be offended if the result is erroneous and an investigation is performed. Should we be limiting usage of opioids in epidurals to select patients such as those experiencing a traumatic birth? Should we identify a standard protocol for testing in these patients? As we progress into a new era of medicine, it would behoove us to take a closer look at the appropriateness of opioids in epidurals for labor and delivery.