A Comparison of Intranasal Fentanyl, Subcutaneous Fentanyl and Intramuscular Pethidine during Childbirth: A Randomised Controlled Trial

Author: Julie-Anne Fleet

Fleet, Julie-Anne, 2015 A Comparison of Intranasal Fentanyl, Subcutaneous Fentanyl and Intramuscular Pethidine during Childbirth: A Randomised Controlled Trial, Flinders University, School of Nursing & Midwifery

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Background Administration of intramuscular (i.m.) pethidine is the standard practice in many maternity units for women who request analgesia during labour (Jones et al. 2012). Yet pethidine has a slow onset and has potential adverse effects for both the mother and neonate (Anderson 2011). Other opioids have been used in childbirth with varying success, for example, fentanyl. When compared to intravenous (i.v.) PCA pethidine, i.v. PCA fentanyl produced fewer adverse effects in the mother and baby (Douma et al. 2010; Rayburn et al. 1998), but this route of administration restricts the woman’s ability to ambulate and requires additional resources, such as programmable PCA pumps and associated equipment. In other clinical settings, fentanyl has proved effective when administered by intranasal (i.n.) and subcutaneous (s.c.) routes, but the efficacy of these routes have not been examined during childbirth. This study compared the clinical effectiveness of i.n. fentanyl, s.c. fentanyl and i.m. pethidine in labouring women requesting analgesia. Methods This randomised controlled trial, a three-arm parallel group design, was undertaken in two settings: the largest tertiary referral centre for maternal care in South Australia (SA) and a regional maternity unit. Parturients were randomised to receive i.n. fentanyl (n=52), s.c. fentanyl (n=53) or i.m. pethidine (n=51). The sample size calculation was undertaken to address the primary outcome, which was reduction of pain score using the Visual Analogue Scale (VAS) at 30 minutes post-treatment. Other maternal variables examined included: experiences of personal control during childbirth, level of sedation, antiemetic use, vital signs, labour duration and birth outcomes. Intention to use the treatment again and breastfeeding outcomes also were recorded post-birth. Neonatal outcomes examined included: Apgar scores at 1 and 5 minutes, arterial cord blood pH and nursery admission. The outcomes were analysed by intention-to-treat. Results All three groups reported clinically significant reductions in pain scores 30 minutes post-administration (mean reduction: 1.2 i.n. fentanyl, 1.1 s.c. fentanyl, 1.6 i.m. pethidine; p<0.001), with no significant differences between groups. While experiences of personal control during childbirth were similar, 82.9% of parturients in the i.n. fentanyl group and 80.6% in the s.c. fentanyl group reported that they would use the treatment again, as compared to only 44.0% of women receiving pethidine (p<0.001). In addition, women in both fentanyl groups were observed to have significantly less sedation 30 minutes post-treatment (p≤0.03), and shorter labours by at least 2 hours (p<0.05). There were no differences between groups for Apgar scores, but neonates in the pethidine group were more likely to require nursery admission post-birth (p<0.02). Women in the pethidine group also were more likely to report difficulty with the establishment of breastfeeding within the first 6 weeks postpartum as compared to women in the fentanyl groups (p<0.01). Conclusion Fentanyl administered via the i.n. and s.c. routes is as efficacious in relieving labour pain as i.m. pethidine and results in greater satisfaction to use the treatment, less sedation, shorter labour, fewer neonatal admissions to nursery and fewer difficulties in the establishment of breastfeeding. This RCT provided evidence that fentanyl is a suitable alternative to pethidine in providing parenteral pain relief to labouring women. Trial registration ACTRN12609001027202

Keywords: fentanyl, pethidine, labour, pain relief, analgesia
Subject: Midwifery thesis, Nursing thesis

Thesis type: Doctor of Philosophy
Completed: 2015
School: School of Nursing & Midwifery
Supervisor: Dr Ingrid Belan