Epidural labour pain relief
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Epidural labour pain relief

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Three years experience of labour epidural analgesia

Three years experience of labour epidural analgesia

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Epidural labour pain relief Epidural labour pain relief Presentation Transcript

  • Epidural Labour Analgesia (pain relief of child birth) Dr Ashok Jadon, MD DNB MNAMS Aesculap IPM Fellowship Senior Consultant & HOD Anaesthesia Tata Motors Hospital, Jamshedpur, India
  • Scope
    • Introduction & Need for labour analgesia
    • Pain Pathways
    • Methods
    • Epidural analgesia
      • Walking epidural
      • Our 3 yrs Experience
  • Introduction & Need for labour analgesia
    • Pain undesirable experience
    • Labour pain
      • Intense
      • Non-essential for progress of labour
      • Undesirable side effects
      • on mother & Baby
  • Most severe pain
  •  
  • Effects of labour pain
  • Management of Labour Pain
  •  
  •  
    • Simplicity
    • Safety
    • Preservation of fetal homeostasis
    Gold Standard ; Epidural analgesia
    • Before starting to insert the epidural, an intravenous drip is put in place.
    • Epidurals are inserted using a sterile technique, with the anaesthetist wearing a sterile gown and gloves.
    • The patient’s back is washed with an antiseptic solution and then a sterile drape is placed over the area.
    • Local anaesthetic is injected into the skin over the spine, to numb the area where the epidural is to be inserted.
    • A fine plastic tube (epidural catheter) is threaded through the needle.
    • The anaesthetist removes the epidural needle, leaving the epidural catheter in place.
    • A special connector is attached to the epidural catheter to allow more local anaesthetic to be given.
    • Further doses of local anaesthetic may given through the filter and connector either manually or using an electronic pump.
    • The epidural catheter is held in place by tape.
  •  
    • An epidural may provide good pain relief for the duration of labour.
    • Thanks to Heidi and John for permission to use their photos.
  •  
  • COMPLICATIONS
      • TOTAL SPINAL BLOCKADE
        • Dural puncture with inadvertent subarachnoid injection
      • HYPOTENSION
        • Normal preg women hypotension can be prevented by rapid infusion of 500-1000ml of crystalloid solution
      • CENTRAL NERVOUS STIMULATION
      • MATERNAL PYREXIA
        • Mean temperature ↑
        • Significantly associated with neonatal sepsis evaluation and antibiotic therapy
        • Presence of pl inflammation
        • Due to infection rather than the analgesia itself
        • Pyrexia : associated with a higher incidence of IU infection from longer 1 st stage labor
      • BACK PAIN
  • EFFECT ON LABOR
      • Epidural analgesia usually prolongs the 1 st stage of labor, increases the need for labor stimulation with oxytocin
  • Epidural analgesia
    • Did not significantly increase cesarean deliveries in either nulliparous or parous women in any individual trial or in their aggregate
  • TIMING OF EPIDURAL PALCEMENT
      • No increase in either operative vaginal delivery or cesarean delivery with early (≤3cm dilatation) administration of epidural analgesia compared with later administration
      • Parkland Hospital : not begun prior to 3-5cm Cx dilatation
    • SAFETY
      • 1968-1985, 26000 women : no maternal deaths
    • CONTRAINDICATIONS
      • actual or anticipated serious maternal hemorrhage, infection at or near the sites for puncture, suspicion of neurological disease
  • SEVERE PREECLAMPSIA-ECLAMPSIA
        • Ideal labor analgesia for women with severe preeclampsia : controversial
        • Past two to three decades, most obstetrical anesthesiologists : favor epidural blockade for labor and delivery in women with severe pre-ecalmpsia
        • 1995, Wallace and colleagues : GA and RA are equally acceptable for cesarean delivery in women with severe pre-ecalmpsia
  • INTRAVENOUS FLUID PRELOADING
      • Most authorities recommend prehydration, usually with 500~1000ml of crystalloid solution
      • Aggressive volume replacement in severe preeclampsia women increases their risk for pul edema, especially in the first 72 hrs postpartum
      • No instances of pul edema in 738 women in whom crystalloid preload was limited to 500ml
  • EPIDURAL OPIATE ANALGESIA
      • Injection of opiates into the epidural space to relieve pain from labor become popular -> rapid onset of pain relief, decrease in shevering, less dense motor blockade
      • Side effect : pruritus(80%), urinary retention(55%), N/V(45%), headaches(10%)
  • COMBINED SPINAL-EPIDURAL TECHNIQUES
      • No consensus regarding maternal Cx when comparing spinal or epidural analgesia with combined techniques
      • Parkland Hospital : 1223 women with uncomplicated term preg (CSEA Vs IV meperidine)
        • Emergency c/sec for profound fetal tachycardia
        • Fetal bradycardia occurred within 30min
        • None of the cases responded to conservative measures
        • Avoid the combined spinal-epidural
  • Our technique
    • CSEA: 3 cases
    • Epidural L2/ L3, Sitting/ lateral
      • 12 ml 0.125% bupivacaine
      • Infusion 0.08% (0.125% --0.0625%)
      • No opioid ( Fentanyl, sufentanyl)
      • Breakthrough pain & Episiotomy
      • 0.125%- 0.25% bupivacaine
      • LSCS: 2% xylocaine with Adren. 15-20ml
  • Results..
    • Number of case =250
    • Vaginal Deliveries: (56%)
    • Forceps application:(22%)
    • LSCS : (22%)
    78%
  • Results..
    • APGAR
      • Vaginal Del: 9.7 + 0.64
      • Forceps: 9 + 1.3
      • LSCS: 8.1 + 1.8
    • Duration of labour (Min) 310 + 143
    • Minimum: 25 min
    • Max: 12 hrs
  • Results..
    • Satisfaction
      • Highly satisfied: 72%
      • Satisfied: 20%
      • Not sure: 2%
      • Dissatisfied: 6%
    • Catheter failure= 4 ( 4%) ( LSCS in both)
    • Dural Puncture= 2 (2%) ; No PDPH
    • Abnormal Paresthesia =2 (2%)
    • Serious Complication= Nil
    92%
  • Our first patient;
  • Journey does not end here, we have to set new targets…….. Thank you very much