Epidural analgesia is the most effective method for relieving labor pain. It involves inserting a catheter into the epidural space to administer local anesthetics that block pain signals while preserving motor function. Potential complications are rare and include hypotension, ineffective analgesia, and prolonged labor. However, epidural analgesia improves maternal and neonatal outcomes by reducing stress and allowing for more effective pushing with no adverse effects on the fetus. It is considered the gold standard for pain relief during labor and delivery when medically appropriate.
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
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.
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
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
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)
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