Rapid obstetric analgesia by means of intravenous vinbarbital sodium

RAPID

OBSTETRIC

ANALGESIA VINBARBITAL

HAROLD F. BURKONS, (From the Department

of

BY MEANS SODIUM”

I

OF INTRAVENOUS

M.D., CLEVELAND,

OHIO

Obstetrics and Gynecology, St. L&e’s

Hospital)

T

HERE are many instances in obstetrics in which rapid induction of anal: gesia is desirable. Particularly is this so in the case of the fast-moving multipara who presents herself at the hospital with cervix half dilated and pains of two- to three-minute intervals and of almost intolerable severity. By the time the usual oral or intramuscular medication takes effect, the patient is likely to be ready for delivery without any noticeable amelioration of her screamprovoking pain. Recent published reports by Evans1 and Lewis2 concerning the efficiency and safety ‘of intravenous vinbarbital sodium stimulated a desire to investigate further the characteristic aspects of this drug. The swiftness of its action seemed particularly appealing. The material consisted of two hundred patients, of whom 84 were primiparas and 116 were multiparas. TABLE

I.

METHOD

OF DELIVERY

Outlet or low forceps Midforceps Breech extraction Spontaneous Twins

174 10 6 12 2

After considerable trial and error, the two hundred divided into three general groups as regards dosage.

parturients

became

1. Those receiving vinbarbital sodium alone. The usual initial dose was 8 cc. ; however, 10 cc. were used in the larger patients. A small amount was injected later if it was deemed necessary. 2. Those receiving vinbarbital sodium intravenously with scopolamine intramuscularly. The usual schedule was vinbarbital sodium 8 C.C. with scopolamine gr. l/200. Then scopolamine gr. l/300 in sixty minutes. The scopolamine was repeated every sixty to ninety minutes thereafter as needed. 3. Those in whom previous medication of morphine, Demerol, scopolamine, or barbiturates was not suficient to induce satisfactory analgesia. Vinbarbital 5 C.C. was administered intravenously, producing almost immediate analgesia at any time it was so desired. Winbarbital sodium is barbiturate and is distributed used in this study was provided and Dohme, Inc., Philadelphia,

the nonproprietary name for sodium 5- (1-methyl-1-butenyl) under the name of Delvinal Sterile Solution. The material through the courtesy of the Medical-Research Division, Sharp Pa. 549

Maternal

Effect

There was no noticeable variation it1 t,he maternal pulse or respirator) The blood pressure remained ilppl~oxir~lately the same. acwalely th! ;\lIloullt 01 illthough no attempt was nratlc~ to IKI~~HIUC blood lost, following the birth of the baby. the distinct impression was gained that there was no increase in postpartum ldeetling. Tn no case did the medication cause a cessation of labor, although, in some patient.s, there was a period of an hour or so tluring which the contractions were more widely spaced. It is probal)le that, in an occasional case, the labor will stop entirely as it does after any nletlication. These patients were probably not in real labor. Interrogation of the patient twent.y-four hours after tleli\~ery revealed the n,na.lgesic-amnesic effect to be as set forth in Table 11. wte.

The 158 patirnt,s who stated they rt~nlembered nothing in rnmy instances said they were unable even to remember the removal of the needle from the vein. The 38 patient,s who recalled an isolated event,, such as being moved onto the delivery table, were all unanimous in declaring tha,t the pain-relieving action was entirely satisfactor;-. In ot,her words, 98 per rent of t,he parturients felt that they had complete or almost complete relief from pain within five minnt,es after receiving vinbarbital sodium int>ravenousiy. All barbiturates, with or without scopolamine, produce mental aberration in susceptible individuals. These disturbances, a,lthough temporary in nature. may be characterized by excitement, restlessness, delirium, or mild hallucinations. If restlessness is marked, the attending nurse may have to USCrestraint in order to keep the patient, from injuring herself. The parturient is usually unaware of her actions and has no recollect,ion of her behavior when she -Fnll~ awakens from her amnesic state. ’ Early in this study it was observed t,hat restlessness was an uncomfortable factor from the viewpoint of the attending nurse, who had to keep the patient in bed and from injuring herself. Careful notes were kept concerning the degree of excitement exhibited bp the second one hundred individuals in this series of cases. The results are tabulated in Table III. The first two groups, of 86 per cent, showed slight to moderate restlessness ‘with pains. The last t,wo groups, or 14 per cent, required restraint in varying

VINBARBITAL

SODIUM

551

AXALGESIA

degree and proved to be rather difficult to manage. The restlessness was only slightly less marked in the individuals receiving vinbarbital alone without scopolamine. TABLE

III.

RESTLESSNESS

DURING

LABOR

-__ Slight restlessness Moderate restlessness Marked restlessness Marked restlessness

with pains with pains with pains during and

between

61 25 11 3

pains

per per per per

cent cent cent cent

After delivery, the vast majority of new mothers slept soundly for different periods of t,ime. A few patients tossed about in bed or talked incoherently. Two pat’ients got out of bed and walked briefly about the room with no apparent, harm to themselves.

Effect on Baby Many investigators have noted that almost all medicaments used in obstetrics for labor-pain relief result in a certain percentage of infants with delayed respiration. Of even more depressing effect are the various inhalation general anesthetics used at the time of delivery. The delivery of the two hundred patients being analyzed here was accomplished by means of drop ether or terminal spinal anesthesia. The delay, if any, in the establishment of regular fetal respiration was accurately determined by means of a st,op watch, thus eliminating the factor of guess work. . In order to exclude the complicating depressing effect of the volatile general anesthetics. the following table (Table IV) includes only the cases delivered with terminal spinal anesthesia. There were seventy-five patients in this group in whom labor of average length was relieved by means of intravenous vinbarbital sodium, with or without scopolamine, and who were delivered with spinal anesthesia. TABLE RESPIRATION Immediate 0 to 30 seconds 30 to 60 seconds 60 to 90 seconds 90 to 120 seconds _______

to 23 to

minutes 34 minutes

IV.

DEI,AY

IN FETAL

RESPIRATION

NO. CASES 38 11 9 4 5 ::5

~__

PER CENT 50.7 14.7 12.0 5.3 6.8 2

Approximately 77 per cent of the babies breathed regularly within sixty seconds after birth. In the remainder, or 23 per cent, resuscitation was instituted and regular respiration established without any particular difficulty. The interval of time between the injection of vinbarbital sodium and the birth of the baby seemed to have very little, if any, influence upon the delay in respiration. In many instances, the medication was administered within thirty to sixty minutes of the time of delivery without adverse effect. The cases in which drop ether anesthesia was used showed a greater incidence and degree of delayed fetal respiration than was observed in the spinally anesthetized patients. Rowever, this delay was, on the average, no greater than that encountered in the patients delivered under the influence of other medications currently in use.

BURKOXS

55%

The delay in respiratory action immediately after birth OWUI’S to ii g~:al(‘~. or lesser degree in the case of all analgesics used durin g label’. especially w1rt!11 thr delivery is accomplished with the aid of general anesthesia. Caudal antsthesia during labor and delivery alone is relatively free of depressing action upon the newborn child. However, caudal anesthesm has its own peculiar disadvantages in other respects. After respiration was established, no further dificulty was encountcrc-htl with any of the neivborn babies. All infants had an uneventful hospital course a.nd were discharged in.good condition. There were two stillbirths in this group, neither of which had any conncction with the use of vinbarbital sodium. One baby was dead on arrival at thtc hospital. The other baby, whose mother had pre-eclamptic toxemia with a.blat.io placentae, died soon after the medication was administered. Summary

and Conclusions

1. The series of cases presented here consists of two hundred carefully observed obstetric patients in whom labor-pain analgesia was accomplished b: the use of intravenous vinbarbital sodium, 2. The appealing feature of this form of obstetric analgesia is its rapidity of action and its reliability. Approximately 98 per cent of the parturients acknowledged highly satisfactory results; 79 per cent received complete analgesia and 19 per cent recalled only an occasional isolated event. The onset of pain relief was quick, occurring within five minutes. Results were unsatisfactory in the remaining 2 per cent. 3. Maternal pulse, respiration, and blood pressure remained within normal limits. Postpartum bleeding was not increased. 4. Restlessness requiring restraint by the attending nurse occurred in 1-I per cent of the cases studied. 5. Although there was delay in the establishment of regular respirator3 action in some newborn babies, in no case was this marked or worrisome. 6. Based on invest,igation to date, intravenous vinbarbital sodium is an effective medication for use in achieving rapid obstetric analgesia. It is particularly useful in t,he fast-moving multipara. Not&-Since in approximately

submission of this report, this preparation 250 cases wit,h similar result?.

References I, Evans, J. R.: AM. J. OBST. & GYNEC. 47: 821-825, 1944. 2. Lewis, M. S.: Aaa. J. OBST. & GYNEC. 51: 395402, 1946. 10300 CARNEGIE AVENUE

has been used ir~t,ruvenonsl~-