Epidural labour pain relief


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Three years experience of labour epidural analgesia

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Epidural labour pain relief

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