Chapter 41: Epidural Morphine Following Vaginal Delivery

BACKGROUND

• Pain after vaginal delivery can interfere with a mother’s daily activities and ability to care for her newborn.

• Acute postpartum pain may be particularly significant for women who have undergone an episiotomy or instrumented delivery, or who have experienced extended perineal tears or uterine involution.

• The use of epidural morphine for select parturients may help to improve pain control after vaginal delivery and reduce the need for oral opioids.^1,2

PATIENT SELECTION

• Did the patient undergo any of the following?

  • Third- or fourth-degree perineal episiotomy or laceration.

  • Prolonged or complicated repair of episiotomy or laceration.

  • Instrumented delivery.

  • Uterine involution.

• Is the patient also complaining of significant pain prior to removal of epidural?

  • A common marker of above average pain is the need for an additional epidural bolus medication following or during the laceration repair.

    • If YES:

• Discuss with the obstetric team and suggest epidural morphine.

• Explain the benefits and possible side effects to patient.

• Consider giving epidural morphine prior to removal of the labor epidural catheter.

CLINICAL PRACTICE

If administration of epidural morphine is desired, the protocol at Beth Israel Deaconess Medical Center is as follows (Chapter 54, “Neuraxial Morphine”):

• Give 1.5 to 2 mg epidural morphine.

• Document the administration dose, time, and route in the online medical record, as the patient will need to be closely monitored for respiratory depression for 18 hours following administration.

  • Include orders for ketorolac, acetaminophen, naloxone bolus, naloxone drip, and antiemetics as provided in the obstetric anesthesia neuraxial morphine order set.

• Hand the neuraxial morphine monitoring form to the nurse and be sure to fill out:

  • Date and time of morphine administration.

  • Date, time, and mode of delivery.

• Give appropriate sign-out to the obstetric team and the nurse.

• The labor and delivery nurse should communicate about the administration of neuraxial morphine with postpartum nursing.

• Alert the obstetric anesthesia team and give sign-out to the oncoming call team.

• Remember: No additional narcotics or sedatives should then be given to the patient for the following 24 hours.

REFERENCES