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Epidural

  1. 1. Labor Epidural Analgesia Prof. Aboubakr Elnashar Benha university, Egypt
  2. 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. 3. Anesthesia: Absence of all sensation, including pain, touch, temperature& pressure. Analgesia: Absence of nociceptive stimuli, with the preservation of motor& touch sensation.
  4. 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. 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. 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
  7. 7. Epidural Analgesia (EA)
  8. 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. 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. 10. Indications Maternal request is sufficient justification during any phase of labor& irrespective of cervical dilatation (ASRM,2001).
  11. 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. 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. 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. 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. 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. 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. 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. 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. 19.  High Level:  High dose  Subdural/subarachnoid migration of catheter  Low level: Inadequate dose Intravenous migration of catheter Catheter outside the epidural space
  20. 20. Patient preparation Nurse Prehydration Non-particulate antacid Monitors Position Preparation Emergency equipment, O2
  21. 21. Procedure 1.Informed consent 2.Monitoring during analgesia induction :  B P/1–2 m for 15 m  verbal communication  Maternal HR.  FHR
  22. 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. 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. 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. 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. 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. 27. 1. Traditional epidurals: Using 0.25%-0.5% bup. High incidence of motor block.
  28. 28. : 2. Low dose epidurals Using 0.125% bup.  High degree of patient satisfaction.  May have some degree of motor weakness.
  29. 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. 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. 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. 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. 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. 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. 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. 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. 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. 38. Late: Post Dural Puncture Headache Epidural Hematoma Epidural abscess Backache
  39. 39. 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
  40. 40. 2. Total Spinal Blockade {Dural puncture with inadvertent subarachnoid injection}.
  41. 41. 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
  42. 42. 4. Central Nervous Stimulation Convulsions: uncommon but serious
  43. 43. 5. Maternal Pyrexia 10-15% Etiology: unclear. (1)Maternal–fetal infection (2)Dysregulation of body temp. Alteration in the hypothalamic thermoregulatory set point
  44. 44. 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)
  45. 45. 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).
  46. 46. 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
  47. 47. 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)
  48. 48. 9. Cesarean Delivery Increased (Sharma & Leveno, 2000) No significant increase (Meta analysis of 14 RCT, Sharma et al, 2004)
  49. 49. 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

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