Oral Ranitidine in Labor

Abstract

Comment: These reviewers question the wisdom of prophylactic antacids or H2 blockers to all women in labor. We do not question the increased risk of the parturient to the catastrophe of pulmonary aspiration of both acid and particulate material. However the danger of particulate aspiration may be increased by the use of oral antacid in suspension and is not decreased by H2 blockers which also interfere with hepatic metabolism and slow breakdown of amide type local anesthetics.1 The vast majority of women in labor today do not require general anesthesia and need not have consciousness and upper airway reflexes sufficiently obtunded by narcotics and sedatives that prevent protection of the airway should vomiting occur. Properly administered conduction analgesia, in which hypotension and local anesthetic toxicity are avoided, do not depress the protective upper airway reflexes. In an emergency procedure requiring general anesthesia, rapid alkalinization of gastric contents is reliably achieved by oral administration of 30 ml 0.3 M sodium citrate or similar soluble antacids (e.g., Bicitra, Alka Seltzer, Gold). Why then do many insist on increasing the workload of labor floor nurses and making mothers uncomfortable by giving them unpleasant and often nauseating mixtures of particulate antacids that, if aspirated, may increase pulmonary problems.2 The administration of expensive systemic H2 blockers that have rare but potential serious side effects is also questionable. Should not the above preparations be reserved for obstetric patients undergoing elective general anesthesia or having symptoms of gastric reflux? Would it not be more prudent to invest the time and money spent on these questionable prophylactic methods in the assurance that the parturient has adequate monitoring throughout labor and delivery and in providing methods of pain relief that do not compromise the upper airway reflexes? H2 blockers may have a role in prophylaxis or treatment when elective general anesthesia is to be used, or if the patient suffers gastric reflux. In the rare incidence when emergency general anesthesia is required, the use of a soluble antacid and an H2 blocker will be effective in immediately elevating and maintaining the gastric pH above the critical level of 2.5 to 3.0. We suggest that the limited benefits derived from routine prophylactic elevation of gastric pH are more than offset by their costs in money, time, maternal discomfort, and maternal risk.