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Labor Epidural
Analgesia
Prof. Aboubakr Elnashar
Benha university, Egypt
What is the most
painful experiences in
a woman’s life?
Labor pain
What is pain?
Sensation of discomfort
resulting from
stimulation of
specialized nerve
endings.
Anesthesia:
Absence of all sensation, including pain, touch,
temperature& pressure.
Analgesia:
Absence of nociceptive stimuli, with the
preservation of motor& touch sensation.
Labor pains
Unrelieved:
Fetal acidosis& hypoxia in the
following situations:
1. Prolonged labor : maternal
metabolic acidosis
2. Maternal hyperventilation
3. Maternal anxiety:
Increase catecholamine release:
Decrease utero-placental flow
SiteThroughCauseStage
lower
abdomen
T10-L1• Cervical& lower ut segment dilatation
• Uterine contraction
Early 1st
Back,
Perineum
Thigh
L2-S4• Distension of the structures
surrounding the vagina& pelvic outlet.
Late 1st
&2nd
There is an overlap
Goals of Labor analgesia
1. Dramatically reduce of pain
2. Segmental blockade
3. Limited motor block
 Allow ambulation
 Retain ability to push
 Minimal effects on progress of labor
4. Maintain stable hemodynamics
 Minimal effects on fetus
Epidural Analgesia
(EA)
Advantages
The only consistently effective
method of pain relief during labor (ASRM,
2002)
Rapidly achieve surgical analgesia
Limited motor block
Reduction in maternal
catecholamines
hyperventilation
The least depressant: alert
participating mother
Extend the duration to match:
Duration of labor
Postoperative analgesia
Facilitates delivery of:
Twins
Preterm infants
Breech
Blunts hemodynamic effects of
uterine contractions: beneficial
PET
Mitral stenosis
intracranial neuro-vas lesions.
Indications
Maternal request is sufficient justification
during any phase of labor& irrespective of cervical
dilatation (ASRM,2001).
Timing
Early vs. late
Higher rate of CS
(Retrospective studies : Lieberman, 1996; Rogers, 1999; Seyb, 1999).
No difference in CS, forceps delivery, or f malposition
(RCT: Chestnut et al,1994; Luxman et al, 1998).
Do not wait until a certain degree of cervical dilatation
or f station is reached before instituting EA
(Eltzschig et al, 2003)
Women in labor should not be required to reach 4 to 5
cm of cervical dilatation before receiving EA
(ACOG, 2002)
Contraindications
 Absolute
 Patient refusal
 Coagulopathy
 Platlets <50 x 106/l.
 Infection at the needle site
 Severe maternal hypovolemia
 Relative
 Severe cardiac disease: aortic stenosis, Esinmenger
 Neurological disease: spina bivda
 Increased intracranial pressure
 Actual or anticipated serious maternal hge
Precautions
1. Anticoagulation
increased risk for spinal cord hematoma&
compression
Guidelines ACOG, 2002
Unfractionated heparin
Therapy:
RA if aPTT is normal
Prophylactic or low-dose aspirin:
No increased risk& can be offered RA
Low-mol-wt heparin
Once-daily:
RA should not be placed until 12 h after last injection.
Withheld for at least 2 h after removal of E catheter.
Twice-daily:
it is not known whether delaying RA for 24 h after the
last injection is adequate.
2. Severe PE–E.
Ideal labor analgesia is controversial.
EA:
Hypotension{sympathetic blockade}
Dangers from pressor agents given to
correct hypotension
Pul edema {infusion of large vol of
crystalloid}.
GA:
Tracheal intubation:
Severe, sudden hypertension:
Pul or cerebral edema or intracranial hge.
EA:
Preferred (Cheek and Samuels, 1991; Gambling & Writer, 1999;
Gutsche, 1986).
Can be safely used (ACOG, 2002).
Superior pain relief without a sig increase in mat or
neonatal complications.
To avoid Pul edema:
Prehydration with 500 to 1000 mL of crystalloid solution
Level of analgesia
For
1. Vaginal delivery: block from the T10 to the S5
dermatomes
2. CS: block from the T4 to the S1 dermatomes
Depends upon:
1. Location of the catheter tip:
catheter tip might move from its original location during
the course of labor.
2. Dose, concentration, vol of anesthetic agent
3. Position of mother:
head-down, horizontal, or head-up
4. Individual variations in the epidural space:
synechiae may preclude a completely satisfactory block.
 High Level:
 High dose
 Subdural/subarachnoid migration of catheter
 Low level:
Inadequate dose
Intravenous migration of catheter
Catheter outside the epidural space
Patient preparation
Nurse
Prehydration
Non-particulate antacid
Monitors
Position
Preparation
Emergency equipment, O2
Procedure
1.Informed consent
2.Monitoring during analgesia induction :
 B P/1–2 m for 15 m
 verbal communication
 Maternal HR.
 FHR
3. Hydration:
500 to 1000 mL of L R
4. Position:
lateral decubitus or sitting
5. The epidural space: identified with a loss-of-
resistance
6. E catheter is threaded 3–5 cm into the E space.
7. Test dose:
3 mL of 1.5%lidocaine with 1:200,000 epinephrine
is injected after careful aspiration& after uterine
contraction
{minimizes the chance of confusing tachycardia that
results from labor pain with tachycardia from IV injection
of the test dose}.
8. If the test dose is negative:
one or two 5-mL doses of 0.25%bupivacaine are injected
to achieve a cephalad sensory T10 level.
9. Assess the block:
After 15–20 m
loss of sensation to cold or
pinprick.
No block :
Catheter is replaced.
Block is asymmetrical:
Catheter is withdrawn 0.5–1.0
cm
Additional 3–5 mL of
0.25%bupivacaine is injected.
Block inadequate:
Catheter is replaced.
10. Position:
lateral or semilateral position
{avoid aortocaval compression}.
11. Observation
Maternal BP: /5–15 min.
FHR: continuously.
Level of analgesia& intensity of
motor block: hourly.
Types
1. Traditional epidural.
2. Low dose epidural.
3. Walking epidurals.
4. Patient controlled epidural
5. Continuous epidural infusion.
6. Combined spinal epidural.
1. Traditional epidurals:
Using 0.25%-0.5% bup.
High incidence of motor block.
:
2. Low dose epidurals
Using 0.125% bup.
 High degree of patient satisfaction.
 May have some degree of motor weakness.
3. Walking epidural
Why to walk?
The upright posture shortens the duration of labor
Weight of fetus dilate the cervix
Reduce duration& operative delivery rate.
Using 0.0625% bup.+ FENT 02ųg/ml.
High degree of mat satisfaction.
No motor weakness.
Low incidence of CS.
low dose mobile Vs. traditional epidural
(Comet study, lancet 2001, 1054 pts).
 Increased rate of normal vaginal delivery
 Decreased rate of instrumental vaginal delivery
 Decreased rate of CS
4. Patient controlled epidural analgesia (PCEA):
Advantages:
 Flexibility& benefit of self administration
 Ability to minimize drug dosage
 Reduced demand on professional time
Disadvantages:
 May provide uneven block
Addition of a basal infusion provides:
 More even block
 Greater maternal satisfaction
 Lower dose requirement than continuous infusion
5. Continuous epidural infusion
Advantages:
Maintenance of stable level of
analgesia
More stable maternal HR& BP
with decreased risk of
hypotension
Good pain relief
Less motor block
Maternal& neonatal drug
concentrations safe if used
cautiously
Disadvantages:
 Dose used is high.
 Duration of labor is longer.
 May need rescue dose.
Example:
-0.0625% bupivacaine+fentanyl 2.5 μg/ ml at 12 ml/hr (early labor)+demand
dose: 4 ml q 15 min
-0.125% bupivacaine+fentanyl 2 μg/ml at 8 ml/hr (advanced labor)+ demand
dose: 3 ml q 15 min
6. Combined Spinal epidural (CSE)
Idea:
Reduction of some of the disadvantages of spinal&
epidural anaesthesia, while preserving their advantages
Advantages
Rapid onset of analgesia.
Reliable, fewer failed, or patchy blocks.
Effective sacral analgesia in advanced labor.
Less motor block.
Better patient satisfaction.
Faster cervical dilatation.
Disadvantages
E catheter may go through the hole made in the dura
mater by the spinal needle
Metal particles contamination when inserting the spinal
needle through the epidural needle (scraping off metal
parts): very unusual
E anaesthetic may leak into the subarachnoid space
Dilution& enhanced spread of epidural drugs by CSF
Difficult handling
Technique
•Two separate segments:
Epidural procedure at L2 – L3
Spinal procedure at L3 – L4
•Single segment (needle through needle):
First step: spinal anaesthesia
Second step: placement of epidural catheter
Complications
Safety
•No maternal deaths in 26,000 cases
•Very low incidence of complications (Cochrane Library review, 2004).
Immediate
Nausea
Hypotension
Total Spinal Anesthesia
Hypoventilation
Subdural Injection
Failure to relieve pain
Intravascular injection-systemic local anesthetic toxicity
Nerve injury
Not instant in onset
May be associated with motor block
Urinary Retention
Priuritus
Late:
Post Dural Puncture Headache
Epidural Hematoma
Epidural abscess
Backache
Epidural
1. Hypotension
Most common side effect
{blocking sympathetic tracts}
Prevention:
1. Rapid infusion of 500 to 1000 mL
of crystalloid solution
2. Maintaining lateral position
2. Total Spinal Blockade
{Dural puncture with inadvertent subarachnoid injection}.
3. Ineffective Analgesia
12%: 3 episodes of pain or pressure (Hess et al, 2002).
4%: required GA for CS (Bloom et al;2004).
Risk factors for breakthrough pain:
Nulliparity
heavier fetal weights
epidural catheter placement at an earlier cervical
dilatation.
Perineal analgesia for delivery is difficult to obtain:
low spinal or pudendal block or
systemic analgesia
4. Central Nervous Stimulation
Convulsions: uncommon but serious
5. Maternal Pyrexia
10-15%
Etiology:
unclear.
(1)Maternal–fetal infection
(2)Dysregulation of body temp.
Alteration in the hypothalamic
thermoregulatory set point
6. Back Pain
No relationship
(Breen, 1994; Howell, 2001; MacArthur, 1997)
Postpartum back pain: common
Persistent or chronic back pain: uncommon.
New, long-term backache: No association
(Lieberman &O'Donoghue, 2002)
7. Effect on Labor
Prolongs labor
1st stage: by 42 min (45 min)
2nd stage: 14 min (15 min)
(meta-analysis of 10 prospective, RCT, Halpern et al, 1998)
Increases the need for oxytocin stimulation
(Most studies)
Increase the need for instrumental delivery {prolonged
2nd stage}
No adverse neonatal effects
(Chestnut, 1999; Thorp & Breedlove, 1996).
Avoid arbitrary termination of the 2nd stage.
With effective EA:
Allow 2nd stage of >3 h:
progress in descent of the vertex
No f distress
8. Fetal Heart Rate
No deleterious effects
(Hill et al,2003)
Improved neonatal acid–base status
(systematic review of 8 studies, Reynolds et al, 2002)
9. Cesarean Delivery
Increased
(Sharma & Leveno, 2000)
No significant increase
(Meta analysis of 14 RCT, Sharma et al, 2004)
Conclusion
Our goal is to improve patient care& safety
EA:
 The only consistently effective method of pain
relief during labor
 Maternal request is sufficient justification during
any phase of labor& irrespective of cervical
dilatation
 Very low incidence of complications
 Prolongs labor but no increase in CS, no
deleterious fetal or neonatal effects
Epidural

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Epidural

  • 1. Labor Epidural Analgesia Prof. Aboubakr Elnashar Benha university, Egypt
  • 2. What is the most painful experiences in a woman’s life? Labor pain What is pain? Sensation of discomfort resulting from stimulation of specialized nerve endings.
  • 3. Anesthesia: Absence of all sensation, including pain, touch, temperature& pressure. Analgesia: Absence of nociceptive stimuli, with the preservation of motor& touch sensation.
  • 4. Labor pains Unrelieved: Fetal acidosis& hypoxia in the following situations: 1. Prolonged labor : maternal metabolic acidosis 2. Maternal hyperventilation 3. Maternal anxiety: Increase catecholamine release: Decrease utero-placental flow
  • 5. SiteThroughCauseStage lower abdomen T10-L1• Cervical& lower ut segment dilatation • Uterine contraction Early 1st Back, Perineum Thigh L2-S4• Distension of the structures surrounding the vagina& pelvic outlet. Late 1st &2nd There is an overlap
  • 6. Goals of Labor analgesia 1. Dramatically reduce of pain 2. Segmental blockade 3. Limited motor block  Allow ambulation  Retain ability to push  Minimal effects on progress of labor 4. Maintain stable hemodynamics  Minimal effects on fetus
  • 8. Advantages The only consistently effective method of pain relief during labor (ASRM, 2002) Rapidly achieve surgical analgesia Limited motor block Reduction in maternal catecholamines hyperventilation The least depressant: alert participating mother
  • 9. Extend the duration to match: Duration of labor Postoperative analgesia Facilitates delivery of: Twins Preterm infants Breech Blunts hemodynamic effects of uterine contractions: beneficial PET Mitral stenosis intracranial neuro-vas lesions.
  • 10. Indications Maternal request is sufficient justification during any phase of labor& irrespective of cervical dilatation (ASRM,2001).
  • 11. Timing Early vs. late Higher rate of CS (Retrospective studies : Lieberman, 1996; Rogers, 1999; Seyb, 1999). No difference in CS, forceps delivery, or f malposition (RCT: Chestnut et al,1994; Luxman et al, 1998). Do not wait until a certain degree of cervical dilatation or f station is reached before instituting EA (Eltzschig et al, 2003) Women in labor should not be required to reach 4 to 5 cm of cervical dilatation before receiving EA (ACOG, 2002)
  • 12. Contraindications  Absolute  Patient refusal  Coagulopathy  Platlets <50 x 106/l.  Infection at the needle site  Severe maternal hypovolemia  Relative  Severe cardiac disease: aortic stenosis, Esinmenger  Neurological disease: spina bivda  Increased intracranial pressure  Actual or anticipated serious maternal hge
  • 13. Precautions 1. Anticoagulation increased risk for spinal cord hematoma& compression Guidelines ACOG, 2002 Unfractionated heparin Therapy: RA if aPTT is normal Prophylactic or low-dose aspirin: No increased risk& can be offered RA
  • 14. Low-mol-wt heparin Once-daily: RA should not be placed until 12 h after last injection. Withheld for at least 2 h after removal of E catheter. Twice-daily: it is not known whether delaying RA for 24 h after the last injection is adequate.
  • 15. 2. Severe PE–E. Ideal labor analgesia is controversial. EA: Hypotension{sympathetic blockade} Dangers from pressor agents given to correct hypotension Pul edema {infusion of large vol of crystalloid}. GA: Tracheal intubation: Severe, sudden hypertension: Pul or cerebral edema or intracranial hge.
  • 16. EA: Preferred (Cheek and Samuels, 1991; Gambling & Writer, 1999; Gutsche, 1986). Can be safely used (ACOG, 2002). Superior pain relief without a sig increase in mat or neonatal complications. To avoid Pul edema: Prehydration with 500 to 1000 mL of crystalloid solution
  • 17. Level of analgesia For 1. Vaginal delivery: block from the T10 to the S5 dermatomes 2. CS: block from the T4 to the S1 dermatomes
  • 18. Depends upon: 1. Location of the catheter tip: catheter tip might move from its original location during the course of labor. 2. Dose, concentration, vol of anesthetic agent 3. Position of mother: head-down, horizontal, or head-up 4. Individual variations in the epidural space: synechiae may preclude a completely satisfactory block.
  • 19.  High Level:  High dose  Subdural/subarachnoid migration of catheter  Low level: Inadequate dose Intravenous migration of catheter Catheter outside the epidural space
  • 21. Procedure 1.Informed consent 2.Monitoring during analgesia induction :  B P/1–2 m for 15 m  verbal communication  Maternal HR.  FHR
  • 22. 3. Hydration: 500 to 1000 mL of L R 4. Position: lateral decubitus or sitting 5. The epidural space: identified with a loss-of- resistance 6. E catheter is threaded 3–5 cm into the E space.
  • 23. 7. Test dose: 3 mL of 1.5%lidocaine with 1:200,000 epinephrine is injected after careful aspiration& after uterine contraction {minimizes the chance of confusing tachycardia that results from labor pain with tachycardia from IV injection of the test dose}. 8. If the test dose is negative: one or two 5-mL doses of 0.25%bupivacaine are injected to achieve a cephalad sensory T10 level.
  • 24. 9. Assess the block: After 15–20 m loss of sensation to cold or pinprick. No block : Catheter is replaced. Block is asymmetrical: Catheter is withdrawn 0.5–1.0 cm Additional 3–5 mL of 0.25%bupivacaine is injected. Block inadequate: Catheter is replaced.
  • 25. 10. Position: lateral or semilateral position {avoid aortocaval compression}. 11. Observation Maternal BP: /5–15 min. FHR: continuously. Level of analgesia& intensity of motor block: hourly.
  • 26. Types 1. Traditional epidural. 2. Low dose epidural. 3. Walking epidurals. 4. Patient controlled epidural 5. Continuous epidural infusion. 6. Combined spinal epidural.
  • 27. 1. Traditional epidurals: Using 0.25%-0.5% bup. High incidence of motor block.
  • 28. : 2. Low dose epidurals Using 0.125% bup.  High degree of patient satisfaction.  May have some degree of motor weakness.
  • 29. 3. Walking epidural Why to walk? The upright posture shortens the duration of labor Weight of fetus dilate the cervix Reduce duration& operative delivery rate. Using 0.0625% bup.+ FENT 02ųg/ml. High degree of mat satisfaction. No motor weakness. Low incidence of CS.
  • 30. low dose mobile Vs. traditional epidural (Comet study, lancet 2001, 1054 pts).  Increased rate of normal vaginal delivery  Decreased rate of instrumental vaginal delivery  Decreased rate of CS
  • 31. 4. Patient controlled epidural analgesia (PCEA): Advantages:  Flexibility& benefit of self administration  Ability to minimize drug dosage  Reduced demand on professional time Disadvantages:  May provide uneven block Addition of a basal infusion provides:  More even block  Greater maternal satisfaction  Lower dose requirement than continuous infusion
  • 32. 5. Continuous epidural infusion Advantages: Maintenance of stable level of analgesia More stable maternal HR& BP with decreased risk of hypotension Good pain relief Less motor block Maternal& neonatal drug concentrations safe if used cautiously
  • 33. Disadvantages:  Dose used is high.  Duration of labor is longer.  May need rescue dose. Example: -0.0625% bupivacaine+fentanyl 2.5 μg/ ml at 12 ml/hr (early labor)+demand dose: 4 ml q 15 min -0.125% bupivacaine+fentanyl 2 μg/ml at 8 ml/hr (advanced labor)+ demand dose: 3 ml q 15 min
  • 34. 6. Combined Spinal epidural (CSE) Idea: Reduction of some of the disadvantages of spinal& epidural anaesthesia, while preserving their advantages Advantages Rapid onset of analgesia. Reliable, fewer failed, or patchy blocks. Effective sacral analgesia in advanced labor. Less motor block. Better patient satisfaction. Faster cervical dilatation.
  • 35. Disadvantages E catheter may go through the hole made in the dura mater by the spinal needle Metal particles contamination when inserting the spinal needle through the epidural needle (scraping off metal parts): very unusual E anaesthetic may leak into the subarachnoid space Dilution& enhanced spread of epidural drugs by CSF Difficult handling
  • 36. Technique •Two separate segments: Epidural procedure at L2 – L3 Spinal procedure at L3 – L4 •Single segment (needle through needle): First step: spinal anaesthesia Second step: placement of epidural catheter
  • 37. Complications Safety •No maternal deaths in 26,000 cases •Very low incidence of complications (Cochrane Library review, 2004). Immediate Nausea Hypotension Total Spinal Anesthesia Hypoventilation Subdural Injection Failure to relieve pain Intravascular injection-systemic local anesthetic toxicity Nerve injury Not instant in onset May be associated with motor block Urinary Retention Priuritus
  • 38. Late: Post Dural Puncture Headache Epidural Hematoma Epidural abscess Backache
  • 40. 1. Hypotension Most common side effect {blocking sympathetic tracts} Prevention: 1. Rapid infusion of 500 to 1000 mL of crystalloid solution 2. Maintaining lateral position
  • 41. 2. Total Spinal Blockade {Dural puncture with inadvertent subarachnoid injection}.
  • 42. 3. Ineffective Analgesia 12%: 3 episodes of pain or pressure (Hess et al, 2002). 4%: required GA for CS (Bloom et al;2004). Risk factors for breakthrough pain: Nulliparity heavier fetal weights epidural catheter placement at an earlier cervical dilatation. Perineal analgesia for delivery is difficult to obtain: low spinal or pudendal block or systemic analgesia
  • 43. 4. Central Nervous Stimulation Convulsions: uncommon but serious
  • 44. 5. Maternal Pyrexia 10-15% Etiology: unclear. (1)Maternal–fetal infection (2)Dysregulation of body temp. Alteration in the hypothalamic thermoregulatory set point
  • 45. 6. Back Pain No relationship (Breen, 1994; Howell, 2001; MacArthur, 1997) Postpartum back pain: common Persistent or chronic back pain: uncommon. New, long-term backache: No association (Lieberman &O'Donoghue, 2002)
  • 46. 7. Effect on Labor Prolongs labor 1st stage: by 42 min (45 min) 2nd stage: 14 min (15 min) (meta-analysis of 10 prospective, RCT, Halpern et al, 1998) Increases the need for oxytocin stimulation (Most studies) Increase the need for instrumental delivery {prolonged 2nd stage} No adverse neonatal effects (Chestnut, 1999; Thorp & Breedlove, 1996).
  • 47. Avoid arbitrary termination of the 2nd stage. With effective EA: Allow 2nd stage of >3 h: progress in descent of the vertex No f distress
  • 48. 8. Fetal Heart Rate No deleterious effects (Hill et al,2003) Improved neonatal acid–base status (systematic review of 8 studies, Reynolds et al, 2002)
  • 49. 9. Cesarean Delivery Increased (Sharma & Leveno, 2000) No significant increase (Meta analysis of 14 RCT, Sharma et al, 2004)
  • 50. Conclusion Our goal is to improve patient care& safety EA:  The only consistently effective method of pain relief during labor  Maternal request is sufficient justification during any phase of labor& irrespective of cervical dilatation  Very low incidence of complications  Prolongs labor but no increase in CS, no deleterious fetal or neonatal effects