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Analgesia for Labor and Delivery
 ALWAYS controversial !
 “Birth is a natural process”
 Women should suffer!!
 Concern...
 Garden of Eden

History

Original Sin
God punished Eve: “In sorrow thou shalt bring forth children.”
Genesis 3:16
Formed...
HISTORY
 1847 – James Young Simpson; ETHER
 1853 – John Snow ; CHLOROFORM
- Queen Victoria, 8th child
Chloroform a’ la reine
“The inhalation lasted fifty-three minutes.
The chloroform was given on a
handkerchief in fifteen m...
Chloroform a’ la reine

“Dr Snow gave me the blessed
chloroform and the effect was soothing,
quieting and delightful beyon...
History contd..
 1855
Religious acceptance
Archbishop of Canterbury's (leader of
the Anglican/Episcopal Church) daughter ...
History
 August Bier ,……………..,
Virginia Apgar ,…

 1900 :
Oskar Kreis , used spinal anesthesia for
childbirth for the fi...
 1933 : John Cleland – pain pathways
 1943 : Hingson – Continuous caudal
 1949 : Flowers - Continuous lumbar epid.
DEFINITION OF PAIN
 ISAP - AS AN UNPLEASANT SENSORY
AND EMOTINAL EXPERIENCE
ASSOCIATED WITH ACTUAL
POTENTIAL TISSUE DAMAG...
TERMINOLOGY
NOCICEPTION:DETECTION,TRANSDUCTION,AND
TRANSMISSION OF NOXIOUS STIMULI

NOCICEPTORS:FREE NERVE ENDINGS ACTIVAT...
PHYSIOLOGY OF PAIN

 PATHWAYS
 MEDIATORS
 PERCEPTION
PATHWAYS
 PERIPHERAL AFFERENT(FIRSTORDER NEURON)
|
DORSAL ROOT GANGLION
|
DORSAL HORN(SECOND ORDER)
|
CONTRALATERAL HEMIS...
MECHANISMS

PERIPHERAL
CENTRAL
PERIPHERAL MECHANISMS
NOCICEPTORS:
1.NON MYELINATED(c-fibers)
2.MYELINATED(A-DELTA)
 POLYMODAL.
 A-DELTA- SHARP,HEAT,PR...
CHEMICAL MEDIATORS
 BRADYKININ
 HISTAMINE
 EICOSANOIDS
 SUBSTANCE-P
 5-HT
 ATP
 H2 ION
 OPIOID PEPTIDES
CENTRAL MECHANISMS
 NOCICEPTIVE AFFERENTS
DORSAL ROOT
GANGLION
DORSALHORN
C&SOME A-DELTA SUPERFICIAL LAMINA(1&2)
SOME A-F...
MODULATORS AT SPINAL
CORD

 OPIOID PEPTIDES
 BIOGENIC AMINES
 OTHERS
SUPRASPINAL MODULATION
 PERIAQUEDUCTAL GREY(PAG) MATTER
 DESCENDING INHIBITORY PATH
 LOSS OF RESPONSE TO NOXIOUS STIMUL...
Grading Of Pains
PAIN PATHWAYS
 1st stage of labor – mostly visceral
 Dilation of the cervix and distention of the
lower uterine segment
...
Labor Pain & Stages of Labor

Eltzschig, Leiberman, Camann, NEJM 348; 319:2003
Effects of labor pain
 Maternal hyperventillation
 Hypocarbia – Uteroplacental vasoconstriction
- ODC to left
 ↑O2 cons...
Ill effects Of Pain?
 High risk parturient – Pre-eclampsia
- Cardiac disease
- Asthma
 Marginal uteroplacental circulati...
Labor Analgesia

Non-Pharmacological

Pharmacological
Non-Pharmacological
 Psycho prophylaxis – Lamaze, Doula
 TENS
 Acupuncture
 Hydrotherapy
 Intradermal water inj.
ACUPUNTURE
 Generally two local points and two distal points on the
arms or on the legs are selected.
Begin Acupuncture 4...
TENS
 Beneficial in patients with moderate to severe
contraction pains in an otherwise reasonably
normal labor.
 Very po...
Pharmacological

Systemic
Medications

Inhalational

Regional Blocks
Factors Determining Fetal Drug Levels
 Lipid solubility
 Molecular size
 Total dose of drug
 Concentration gradient
 ...
Systemic Opioids in Labor
Advantages:
 Easy administration
 Inexpensive
 No needles
 Avoids complications of regional ...
Systemic Opioids - Disadvantages
 Placental transfer
 Inadequate pain relief
 Maternal sedation
 Nausea, vomiting, gas...
Potential Fetal/Neonatal Effects
 Low 1 and 5 min Apgar scores
 Respiratory acidosis
 Naloxone/ ventilatory assistance ...
 Mepridine: 50-100mg IM / 25-50mgIV
onset: 45mins
/ 5mins
neonatal depr: 3hrs
/ 20 mins
optimal time: >4hrs
/ <1hr
 Fent...
IV-PCA Fentanyl during Labor
 Loading dose -50-100µg
 No background infusion
 10-12.5µg bolus
 8-10 min lockout
 4 ho...
Inhalation Analgesia
Entonox (N2O:O2 = 50:50), %,

Advantages:
 Easy to administer (no
needles or PDPH)
 “Satisfactory” ...
Inhalational Analgesia
 Isoflurane ( 0/2%)
 Enflurane (0/2%)
 Desflurane (0/2%)
LIMITED USE
Drowsiness ,Unpleasant smel...
Inhalation Analgesia
Disadvantages:
 Decreased uterine contractility (except N2O)
 Rapid induction of anesthesia in preg...
Regional blocks
Paracervical Block
 Local bilateral injection near the cervix
 Given during 1st stage of labor
 Lasts about 2 hours
 D...
Pudendal Block
 Perineal anaesthesia
 Second stage of labor
Neuraxial Blocks - advantages





Most effective & Least depressant
Great versatility – Extent & Duration
Reduces mat...
Regional Analgesia - Neonatal Effects
 Uterine perfusion maintained
 FHR changes:
 baseline variability


periodic dec...
Indications
PAIN EXPERIENCED BY A WOMAN IN LABOR
 ACOG and ASA stated
“ in the absence of a medical contraindication,
mat...
Particularly beneficial
 Hypertensive disorders
 Cardiac disease
Blunts Haemodynamic
response
 Asthma
 Diabetes
 Prol...
Maternal catecholamines decrease during labor
after lumbar epidural analgesia.

Am J Obstet Gynecol 1983;147:13-5.
Contraindications
ABSOLUTE
 Patients refusal
 Inability to cooperate
 Increased intracranial
pressure
 Infection at th...
GOALS OF LABOR ANALGESIA
 Dramatically reduce pain of labor
 Should allow parturients to participate in birthing
experie...
How to Achieve Goals:
 What you put in:
Drugs, concentrations, combinations

 How you deliver it:
Intermittent boluses, ...
Neuraxial Blocks




Epidural alone
Combined epidural and spinal
Spinal alone

 Local anaesthetics(LA) alone
 Opioids...
Neuraxial Blocks
 Spinal opioids alone: very high risk pts
 Epidural opioids alone: High doses
 Spinal LA alone: Saddle...
Choice Of Local Anesthetic
 Rapid onset with minimal motor block
 Minimal risk of maternal toxicity
 Negligible effects...
Choice of Epidural LA
 Lignocaine: Rapid onset, Dense motor block, Risk of
cummulative toxicity, UV/MV ratio – 0.6

 Chl...
Epinephrine Use in Labor
 May transiently slow labor
 Increases motor block, Improves analgesia
 Epinephrine test dose ...
Epidural Opioids in Labor
 Inadequate analgesics if used alone
 Synergize with local anesthetics
 Speed onset of analge...
Effect of low conc LA + opioid
(Comet Study UK , Lancet 2001;358:19)
50
%
Patients

40

*

*

*

30
20
10
0

"Traditional"...
Which Epidural Opioid ?
Fentanyl and Sufentanil
 Rapid onset, few side effects
 Sufentanil slightly more effective
 No ...
Light or “Ultra-light Analgesic
Techniques
Bupivacaine
Ropivacaine
+ OPIOID
Levobupivacaine
Epidural analgesia
Opioid: Fentanyl 1-2 µg/ml,
Sufentanyl 0.20.5µg/ml
Continuous infusion
 Bupivacaine 0.0625%-0.25%,8 -1...
Continous Epidural
Continuous epidural infusion
“A larger volume of a more dilute agent is more
effective for labor analgesia than a smaller
...
PCEA






Good analgesia
Patient autonomy
Less anaesthetist interventions
Cost effective
Lower total dose

Bupivacai...
From Gambling DR et al. Comparison of patient-controlled epidural
analgesia and conventional intermittent top up injection...
Combined spinal-epidural
 Faster onset - intense analgesia
 Additional flexibility - epidural
 Very low failure rate
 ...
COMBINED SPINAL EPIDURAL
Needle” through “Needle”

“ Back “ eye”

 Needle” through “Needle” technique is the best
 Can b...
Onset of Analgesia: CSE vs.
Epidural
Collis et al. Lancet 1995;345:1413
100

CSE
Epidural

75

VAPS
(0-100)

50
25
0
Basel...
Combined spinal-epidural
 Not recommended - morbidly obese, difficult airway
or non-reassuring fetal heart rate
 Two int...
Continuous Spinal Analgesia
 28 or 32-G catheters for 22 or 26-G spinal needles
 Bupivacaine 2.5mg+25µg fentanyl,
1-2ml/...
Side effects of IT opioids
Nausea, Vomitting
Pruritis
Sedation
At very high doses - Resp depression
- Fetal bradycardia
 ...
We are All Ready…Now What?
Obstetrician is consulted
Pre-anesthetic evaluation
Pt’s informed consent
Fetal well-being asse...
Conduct of Labour analgesia









Baseline BP, HR, FHR
IV access, Preload 500 -1000ml
Perform epidural / CSE
Pr...
Conduct of Labour analgesia
 Monitoring:
 BP every 1 to 2 min , 20 min
 Continuous maternal HR during induction
(pulseo...
Conduct of Labor analgesia






Nursed in lateral position
Second stage of labor – S2 -4
Head end elevation, 4-8ml d...
Inadequate analgesia







Inadequate dose
Patency of catheter
Subdural placement
Second stage of labor
Catheter mi...
Complications
 Hypotension: preloading, LUD, O2, fluid, ephedrine
 Inadequate analgesia:
 Unintentional intravascular p...
Fetal
Heart
Rate
Management of FHR Changes
 Left uterine displacement
 Maternal position change
 O2 administration

 STOP OXYTOCIN!
 F...
Controversial areas
 Maternal pyrexia:
↑0.1 C/hr, No infection, No neonatal sepsis

 Progress of Labor:
?only minimally ...
Avoiding Epidural Disasters








Maintain constant verbal contact
Always aspirate before each injection
Observe ...
Conclusions
 Individualize technique to patient’s goals and
stage of labor
 Optimize management for spontaneous delivery...
The Ideal Labor Analgesic
 Good pain relief
 No autonomic block (no hypotension)
 No adverse maternal or neonatal effec...
Labour analgesia
Labour analgesia
Labour analgesia
Labour analgesia
Labour analgesia
Labour analgesia
Labour analgesia
Labour analgesia
Labour analgesia
Labour analgesia
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Labour analgesia

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Labour analgesia

  1. 1. Analgesia for Labor and Delivery  ALWAYS controversial !  “Birth is a natural process”  Women should suffer!!  Concerns for mother’s safety  Concerns for baby  Concerns for effects on labor
  2. 2.  Garden of Eden History Original Sin God punished Eve: “In sorrow thou shalt bring forth children.” Genesis 3:16 Formed the basis of 1800 years of opposition to pain relief in labor.  1591 Lady Euframe MacAlyane of Edinburgh, Scotland: was Burned at the Stake because asking for labor analgesia.
  3. 3. HISTORY  1847 – James Young Simpson; ETHER  1853 – John Snow ; CHLOROFORM - Queen Victoria, 8th child
  4. 4. Chloroform a’ la reine “The inhalation lasted fifty-three minutes. The chloroform was given on a handkerchief in fifteen minim doses; the Queen expressed herself as greatly relieved by the administration.”
  5. 5. Chloroform a’ la reine “Dr Snow gave me the blessed chloroform and the effect was soothing, quieting and delightful beyond measure”
  6. 6. History contd..  1855 Religious acceptance Archbishop of Canterbury's (leader of the Anglican/Episcopal Church) daughter received chloroform for labor pains. He refused to criticize.  1860-1940 : Dark ages of obstetric anesthesia
  7. 7. History  August Bier ,…………….., Virginia Apgar ,…  1900 : Oskar Kreis , used spinal anesthesia for childbirth for the first time
  8. 8.  1933 : John Cleland – pain pathways  1943 : Hingson – Continuous caudal  1949 : Flowers - Continuous lumbar epid.
  9. 9. DEFINITION OF PAIN  ISAP - AS AN UNPLEASANT SENSORY AND EMOTINAL EXPERIENCE ASSOCIATED WITH ACTUAL POTENTIAL TISSUE DAMAGE (OR) DESCRIBED IN TERMS OF SUCH DAMAGE.
  10. 10. TERMINOLOGY NOCICEPTION:DETECTION,TRANSDUCTION,AND TRANSMISSION OF NOXIOUS STIMULI NOCICEPTORS:FREE NERVE ENDINGS ACTIVATED BY NOXIOUS STIMULI. PHYSIOLOGIC PAIN:NOXIOUS STIMULI ACTIVATING | NOCICEPTORS ACCOMPANIED BY WITHDRAWAL PATHOLOGIC PAIN: NON NOXIOUS STIMULI PRODUCING PAIN
  11. 11. PHYSIOLOGY OF PAIN  PATHWAYS  MEDIATORS  PERCEPTION
  12. 12. PATHWAYS  PERIPHERAL AFFERENT(FIRSTORDER NEURON) | DORSAL ROOT GANGLION | DORSAL HORN(SECOND ORDER) | CONTRALATERAL HEMISPHERE | SPINOTHALAMIC TRACT | THALAMUS
  13. 13. MECHANISMS PERIPHERAL CENTRAL
  14. 14. PERIPHERAL MECHANISMS NOCICEPTORS: 1.NON MYELINATED(c-fibers) 2.MYELINATED(A-DELTA)  POLYMODAL.  A-DELTA- SHARP,HEAT,PRESSURE  C-FIBERS-DULL BURNING PAIN.  PATHOLOGICAL PAIN-A-BETA.
  15. 15. CHEMICAL MEDIATORS  BRADYKININ  HISTAMINE  EICOSANOIDS  SUBSTANCE-P  5-HT  ATP  H2 ION  OPIOID PEPTIDES
  16. 16. CENTRAL MECHANISMS  NOCICEPTIVE AFFERENTS DORSAL ROOT GANGLION DORSALHORN C&SOME A-DELTA SUPERFICIAL LAMINA(1&2) SOME A-FIBERS —LAMINA - 5 30% -C-FIBERS —DOUBLE BACK THROUGH VENTRAL ROOT 1&5 -------THALAMUS LAMINA 2—SUBSTANTIA GELATINOSA (INHIBITORY) “THE GATE CONTROL THEORY OF PAIN”
  17. 17. MODULATORS AT SPINAL CORD  OPIOID PEPTIDES  BIOGENIC AMINES  OTHERS
  18. 18. SUPRASPINAL MODULATION  PERIAQUEDUCTAL GREY(PAG) MATTER  DESCENDING INHIBITORY PATH  LOSS OF RESPONSE TO NOXIOUS STIMULI  RESPONSE TO STIMULI-3 WAYS  “ON CELLS” FACILITATE NOCICEPTIVE TRANSMISSION  “OFF CELLS” INHIBITS TRANSMISSION  “NEUTRAL CELLS”NO CHANGE IN FIRING
  19. 19. Grading Of Pains
  20. 20. PAIN PATHWAYS  1st stage of labor – mostly visceral  Dilation of the cervix and distention of the lower uterine segment  Dull, aching and poorly localized  Slow conducting, C fibers, T10 to L1  2nd stage of labor – mostly somatic  Distention of the pelvic floor, vagina and perineum  Sharp, severe and well localized  Rapidly conducting, A-delta fibers,S2 to S4
  21. 21. Labor Pain & Stages of Labor Eltzschig, Leiberman, Camann, NEJM 348; 319:2003
  22. 22. Effects of labor pain  Maternal hyperventillation  Hypocarbia – Uteroplacental vasoconstriction - ODC to left  ↑O2 consumption  ↑Cardiac output, ↑BP  ↑Maternal plasma catecholamines Fetal acidosis and hypoxia
  23. 23. Ill effects Of Pain?  High risk parturient – Pre-eclampsia - Cardiac disease - Asthma  Marginal uteroplacental circulation  Prolonged labor
  24. 24. Labor Analgesia Non-Pharmacological Pharmacological
  25. 25. Non-Pharmacological  Psycho prophylaxis – Lamaze, Doula  TENS  Acupuncture  Hydrotherapy  Intradermal water inj.
  26. 26. ACUPUNTURE  Generally two local points and two distal points on the arms or on the legs are selected. Begin Acupuncture 4 weeks before the expected time of delivery. Needles are placed once a week using the specific points.  Points LI.4 Hegu, SP.6 Saninjiao, Extra Neima PC 6 (Neiguan), Du.20,Du.2,Du6, GB.21, He.7(shenmen)
  27. 27. TENS  Beneficial in patients with moderate to severe contraction pains in an otherwise reasonably normal labor.  Very popular in Europe.  Easy to apply, non-toxic and frequently effective.  4 electrodes are placed one on either side of the spine in the lower thoracic region (T 10) and one on either side of the spine in the sacral area.  The patient may control up to 3 levels of intensity of stimuli, and she can switch it off if she wishes.
  28. 28. Pharmacological Systemic Medications Inhalational Regional Blocks
  29. 29. Factors Determining Fetal Drug Levels  Lipid solubility  Molecular size  Total dose of drug  Concentration gradient  Maternal metabolism and excretion  Degree of ionization  pKa of drug, maternal and fetal pH  Protein binding - mother and fetus  Uterine blood flow  Time for equilibrium to occur
  30. 30. Systemic Opioids in Labor Advantages:  Easy administration  Inexpensive  No needles  Avoids complications of regional block  Does not require skilled personnel  Few serious maternal complications  Perceived as “natural”
  31. 31. Systemic Opioids - Disadvantages  Placental transfer  Inadequate pain relief  Maternal sedation  Nausea, vomiting, gastric stasis  Fetal heart rate effects:  Loss of beat-to-beat variability  Sinusoidal rhythm  Dose-related maternal / neonatal depression  Newborn neurobehavioral depression
  32. 32. Potential Fetal/Neonatal Effects  Low 1 and 5 min Apgar scores  Respiratory acidosis  Naloxone/ ventilatory assistance may be needed  Neurobehavioral depression - dose dependent  Occasionally, prolonged observation in NICU needed
  33. 33.  Mepridine: 50-100mg IM / 25-50mgIV onset: 45mins / 5mins neonatal depr: 3hrs / 20 mins optimal time: >4hrs / <1hr  Fentanyl: 50-100µg/hr, peaks @ 3-5mins  Remifentanil : ½life 6mins, 0.5mirogms/kg  Butraphanol, Nalbhuphine, Phenothiazines
  34. 34. IV-PCA Fentanyl during Labor  Loading dose -50-100µg  No background infusion  10-12.5µg bolus  8-10 min lockout  4 hour limit - 300 mcg  Pulse oximeter when large doses
  35. 35. Inhalation Analgesia Entonox (N2O:O2 = 50:50), %, Advantages:  Easy to administer (no needles or PDPH)  “Satisfactory” analgesia variable  Minimal neonatal depression
  36. 36. Inhalational Analgesia  Isoflurane ( 0/2%)  Enflurane (0/2%)  Desflurane (0/2%) LIMITED USE Drowsiness ,Unpleasant smell, High cost, Accidental overdose
  37. 37. Inhalation Analgesia Disadvantages:  Decreased uterine contractility (except N2O)  Rapid induction of anesthesia in pregnancy  Risk of unconsciousness and aspiration  Difficulties with scavenging in labor rooms
  38. 38. Regional blocks
  39. 39. Paracervical Block  Local bilateral injection near the cervix  Given during 1st stage of labor  Lasts about 2 hours  Disadvantage  fetal bradycardia  Lidocaine toxicity
  40. 40. Pudendal Block  Perineal anaesthesia  Second stage of labor
  41. 41. Neuraxial Blocks - advantages     Most effective & Least depressant Great versatility – Extent & Duration Reduces maternal Catechols ↑Intervillous blood flow    Improved Uteroplacental perfusion Low dose LA – NO Effect on Uterine activity Low dose opioids – NO neonatal depression
  42. 42. Regional Analgesia - Neonatal Effects  Uterine perfusion maintained  FHR changes:  baseline variability  periodic decelerations (due to↓ maternal catechols?)  Apgar scores, acid-base status - unaffected  Neurobehavioral effects absent  LA toxicity - extremely rare  Profound hypotension - possible fetal compromise
  43. 43. Indications PAIN EXPERIENCED BY A WOMAN IN LABOR  ACOG and ASA stated “ in the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief…”  Points of controversy  When?  Who?  How?
  44. 44. Particularly beneficial  Hypertensive disorders  Cardiac disease Blunts Haemodynamic response  Asthma  Diabetes  Prolonged lobor/ Oxytocin augmentation Depressant  Prematurity effects of opioids  Multiple gestation avoided  Vaginal breech delivery
  45. 45. Maternal catecholamines decrease during labor after lumbar epidural analgesia. Am J Obstet Gynecol 1983;147:13-5.
  46. 46. Contraindications ABSOLUTE  Patients refusal  Inability to cooperate  Increased intracranial pressure  Infection at the site  Frank coagulopathy  Hypovolemic shock RELATIVE  Systemic maternal infection  Preexisting neurological deficiency  Mild coagulation abnormalities  Relative hypovolemia  Poor communication
  47. 47. GOALS OF LABOR ANALGESIA  Dramatically reduce pain of labor  Should allow parturients to participate in birthing experience  Minimal motor block to allow ambulation  Minimal effects on fetus  Minimal effects on progress of labor
  48. 48. How to Achieve Goals:  What you put in: Drugs, concentrations, combinations  How you deliver it: Intermittent boluses, Continuous, PCEA  How much you give: Low Vs. High infusion rates
  49. 49. Neuraxial Blocks    Epidural alone Combined epidural and spinal Spinal alone  Local anaesthetics(LA) alone  Opioids and LA  Opioids alone
  50. 50. Neuraxial Blocks  Spinal opioids alone: very high risk pts  Epidural opioids alone: High doses  Spinal LA alone: Saddle block, 6mg bupivacaine Epidural LA alone Epidural LA + Opioid ± Adjuvants Combined Spinal & epidural – LA+Opioid ± Adjuvants  Continuous spinal – LA ± Opioids   
  51. 51. Choice Of Local Anesthetic  Rapid onset with minimal motor block  Minimal risk of maternal toxicity  Negligible effects on uterine activity and uteroplacental perfusion  Limited uteroplacental transfer  Long duration of action
  52. 52. Choice of Epidural LA  Lignocaine: Rapid onset, Dense motor block, Risk of cummulative toxicity, UV/MV ratio – 0.6  Chlorprocaine:Rapid onset, Low toxicity, Dense block, Antagonises bupivacaine &poioids  Bupivacaine( 0.0625%): Good sensory, Minimal motor block, 2hrs, No adverse effects on labor, UV/MV – 0.3  Ropivacaine: Lower toxicity, ?Less motor block, Less potent  Levobupivacaine: Lower toxicity
  53. 53. Epinephrine Use in Labor  May transiently slow labor  Increases motor block, Improves analgesia  Epinephrine test dose often avoided in labor  Low specificity - maternal heart rate very variable  Low sensitivity - ↓ response to sympathomimetics  Increases motor block - prevents ambulation  Potential for ↓ UBF with repeated doses  Very dilute agents - “whole first dose is test dose.”
  54. 54. Epidural Opioids in Labor  Inadequate analgesics if used alone  Synergize with local anesthetics  Speed onset of analgesia  Improve quality of analgesia  Permit use of very dilute LA solutions  Help relieve persistent perineal pain and unblocked segments
  55. 55. Effect of low conc LA + opioid (Comet Study UK , Lancet 2001;358:19) 50 % Patients 40 * * * 30 20 10 0 "Traditional" Bupivacaine 0.25% Low-dose Infusion Bupiv 2.5 mg + Fent 25 mcg Bupivacaine 0.1% + fentanyl Spontaneous Instrumental C/Section
  56. 56. Which Epidural Opioid ? Fentanyl and Sufentanil  Rapid onset, few side effects  Sufentanil slightly more effective  No significant fetal drug accumulation  No serious adverse neonatal effects
  57. 57. Light or “Ultra-light Analgesic Techniques Bupivacaine Ropivacaine + OPIOID Levobupivacaine
  58. 58. Epidural analgesia Opioid: Fentanyl 1-2 µg/ml, Sufentanyl 0.20.5µg/ml Continuous infusion  Bupivacaine 0.0625%-0.25%,8 -15 ml/hr  Ropivacaine: 0.125%-0.25%, 6 -12 ml/hr Intermittent bolus injections  Bupivacaine: 0.125%-0.375%, 5-10 ml, duration:1-2 hr
  59. 59. Continous Epidural
  60. 60. Continuous epidural infusion “A larger volume of a more dilute agent is more effective for labor analgesia than a smaller volume of higher concentration”  Good pain releif  Less motor block  Increased maternal hamodynamic stability  Safe drug concentrations  No change in neonatal outcome
  61. 61. PCEA      Good analgesia Patient autonomy Less anaesthetist interventions Cost effective Lower total dose Bupivacaine 0.125% + Fentanyl 2µg/ml – 6ml basal infusion, 3ml bolus, 10min lockout interval, max 24ml/hr
  62. 62. From Gambling DR et al. Comparison of patient-controlled epidural analgesia and conventional intermittent top up injections during labor. Anesth Analg 1990;70:256-61.
  63. 63. Combined spinal-epidural  Faster onset - intense analgesia  Additional flexibility - epidural  Very low failure rate  Minimal motor block if only opioid used for spinal  Less need for supplemental boluses  IT opioids: Fentanyl 5-25 μg, sufentanil 5-10 μg Early labor : opioid ± 0.125 mg bupivacaine; Advanced labor: opioid ± 2-2.5 mg bupivacaine
  64. 64. COMBINED SPINAL EPIDURAL Needle” through “Needle” “ Back “ eye”  Needle” through “Needle” technique is the best  Can be placed in lateral or sitting position  Walking Epidural possible
  65. 65. Onset of Analgesia: CSE vs. Epidural Collis et al. Lancet 1995;345:1413 100 CSE Epidural 75 VAPS (0-100) 50 25 0 Baseline 5 10 Time (minutes) 15 20
  66. 66. Combined spinal-epidural  Not recommended - morbidly obese, difficult airway or non-reassuring fetal heart rate  Two interspace techniques  Needle through needle -PDPH: 1% or less, small bore atraumatic needles. -Subarchanoid migration of epidural catheter - No added risk with CSE
  67. 67. Continuous Spinal Analgesia  28 or 32-G catheters for 22 or 26-G spinal needles  Bupivacaine 2.5mg+25µg fentanyl, 1-2ml/hr of bupivacaine 0.125% + 2µg/ml fentanyl  Cauda Equina Syndrome  Restricted by FDA in 1992  Ongoing multi-institutional study – 28-G catheters sufentanil ± bupivacaine  Appears safe
  68. 68. Side effects of IT opioids Nausea, Vomitting Pruritis Sedation At very high doses - Resp depression - Fetal bradycardia  Stratergy to ↓ side effect - Add LA - Lowest dose opioid    
  69. 69. We are All Ready…Now What? Obstetrician is consulted Pre-anesthetic evaluation Pt’s informed consent Fetal well-being assessed and reassured (obstetrician?, midwife?, yourself?)  Stage of labor/ Cervical dilatation  Resuscitation equipment and drugs are immediately available  Aspiration prophylaxis    
  70. 70. Conduct of Labour analgesia         Baseline BP, HR, FHR IV access, Preload 500 -1000ml Perform epidural / CSE Pregnancy – Physiologic changes Left lateral / sitting R/O intrathecal/ IV placement 3-5cm catheter inside space 4ml of the drug
  71. 71. Conduct of Labour analgesia  Monitoring:  BP every 1 to 2 min , 20 min  Continuous maternal HR during induction (pulseoximetry)  Continuous FHR monitoring  Continual verbal communication     After 5mins, 4-8ml of drug » T10-L1 block Alternatively continuous infusion /PCEA Assess progression of labor Treat every bolus as test dose
  72. 72. Conduct of Labor analgesia      Nursed in lateral position Second stage of labor – S2 -4 Head end elevation, 4-8ml drug bolus Intermittent techniques – 10-15ml drug Prolonged for instrumental delivery / C.section
  73. 73. Inadequate analgesia       Inadequate dose Patency of catheter Subdural placement Second stage of labor Catheter migration Uterine rupture
  74. 74. Complications  Hypotension: preloading, LUD, O2, fluid, ephedrine  Inadequate analgesia:  Unintentional intravascular placement: slow injection of dilute conc – less risk ligonocaine – light headedness, perioral numbness, seizures. Bupivacaine – Ventricular arrythmia, cardiac arrest  Unintentional intrathecal placement: Hypotension, total spinal, PDPH  Subdural placement :patchy block, high level
  75. 75. Fetal Heart Rate
  76. 76. Management of FHR Changes  Left uterine displacement  Maternal position change  O2 administration  STOP OXYTOCIN!  Fetal scalp stimulation  Nitroglycerin: 400 µg sublingual X 2 (or more)  Terbutaline 0.25 mg, subcutaneous  Treat hypotension  Ephedrine -  epinephrine level;  UBF
  77. 77. Controversial areas  Maternal pyrexia: ↑0.1 C/hr, No infection, No neonatal sepsis  Progress of Labor: ?only minimally prolongs  Rate of C/S: Not increased  Epidural test dose: ? Adrenaline, ?isoprotenerol Careful aspiration
  78. 78. Avoiding Epidural Disasters        Maintain constant verbal contact Always aspirate before each injection Observe for passive return through the catheter Do not inject more than 4 ml of LA at a time Observe the patient at least 1.5-2 min between boluses If in doubts, repeat test dose. Still in doubts? Replace it i After all, be mentally prepare to treat 1. Convulsions 2. Total spinal 3. Cardiovascular collapse and arrest
  79. 79. Conclusions  Individualize technique to patient’s goals and stage of labor  Optimize management for spontaneous delivery  Provide safe, cost-effective analgesia
  80. 80. The Ideal Labor Analgesic  Good pain relief  No autonomic block (no hypotension)  No adverse maternal or neonatal effects  No motor block  No effect on labor and delivery:  No increase in C/S rate  No increase in forceps/vacuum delivery  Patient can ambulate  Economical: cost and personnel

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