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Epidural analgesia in labor

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Epidural analgesia in labor

  1. 1. EPIDURAL ANALGESIA IN LABOR
  2. 2. MEDICOLEGAL CONSIDERATIONS <ul><li>valid consent </li></ul><ul><li>patient must be aware of nature of the proposed procedure alternatives including no treat and any risks of complications </li></ul>
  3. 3. ?
  4. 4. Mortality crude overall mortality 1:1000 operations death during anesthesia or within 24hrs 1:13000 complications 1:750 anesthetics death due to anesthesia 1:250000
  5. 5. INDICATIONS FOR EPIDURAL ANALGESIA <ul><li>1. Pain </li></ul><ul><li>2. Preeclampsia </li></ul><ul><li>3. Diabetes </li></ul><ul><li>4. Recent tocolytic therapy </li></ul><ul><li>5. Preterm delivery </li></ul><ul><li>6. Signs of fetal stress </li></ul><ul><li>7. Prolonged rupture of membranes </li></ul><ul><li>8. Multiple gestation </li></ul><ul><li>9. Malpresentation </li></ul><ul><li>10. Small-for-gestational age infants </li></ul>unless contraindications exist
  6. 6. Steps of Epidural Injection
  7. 8. Maternal Complications of Epidurals in Obstetrics <ul><li>Hypotension </li></ul><ul><li>Spinal headache </li></ul><ul><li>Long-term backache </li></ul><ul><li>Maternal nerve injury due to needle injury,poor positioning,instrumental injury,infection,haematoma, subarachnoid injection of solution intend for epidural </li></ul><ul><li>Allergic reaction </li></ul>
  8. 9. Spinal headache <ul><li>The incidence of inadvertent spinal tap is about 1.7% </li></ul><ul><li>The incidence of headache is 85% </li></ul><ul><li>Headache occurs from several hours up to 2 days post puncture </li></ul><ul><li>Bed rest does not prevent it. </li></ul>
  9. 10. Methods of Treatment <ul><li>Wait and see attitude with non-intervention </li></ul><ul><li>Conservative measures </li></ul><ul><li>These will reduce the incidence of headache to 85% </li></ul><ul><li>Opioid analgesia is not effective </li></ul>
  10. 11. Methods of Treatment <ul><li>The use of epidural blood patch is not recommended as a prophylactic measure </li></ul><ul><li>A patch performed within 24 hours has a 70% failure rate (after 24 h -4% ) </li></ul>
  11. 12. Dural Tap Protocol <ul><li>A : Resite the epidural </li></ul><ul><li>Long strenuous pushing is avoided </li></ul><ul><li>Post-delivery,an epidural infusion of Ringers lactate should be set up via the epidural catheter </li></ul><ul><li>1.5 L for 24 h </li></ul><ul><li>B : Use a subarachnoid block </li></ul><ul><li>An end-hole catheter inserted 2 cm only </li></ul><ul><li>Give 1ml initially,of 0.125% plain bupivacaine then 0.5 ml increments of 0.125% or 0.25% </li></ul>
  12. 13. Coagulation and Epidurals <ul><ul><ul><ul><ul><li>Epidural Insertion </li></ul></ul></ul></ul></ul><ul><li>Catheter Removal </li></ul><ul><ul><ul><ul><ul><li>Dural puncture </li></ul></ul></ul></ul></ul>
  13. 14. Coagulation Disorders in Pregnancy Physiological Changes Coagulopathies in Pre-eclampsia Iatrogenic coagulation disorders Diseases associated with coagulation abnormalities
  14. 15. IATROGENIC COAGULOPATHIES <ul><li>Use of NSAD </li></ul><ul><li>Aspirin </li></ul><ul><li>Low molecular weight HEPARIN </li></ul><ul><li>Heparinisation </li></ul>
  15. 16. ASPIRIN LOW-MOLECULAR- WEIGHT HEPARIN or a COMBINATION OF THEM To do or not to do EPIDURALS ???
  16. 17. Analgesia for Labor and Delivery in Toxemia of Pregnancy <ul><li>The best choice is </li></ul><ul><li>REGIONAL ANESTHESIA </li></ul>
  17. 18. ?
  18. 19. Epidural Analgesia for LABOR <ul><li>Initial dose </li></ul><ul><li>Bupivacaine 0.25% - 10 ml </li></ul><ul><li>+ 50  g of Fentanyl </li></ul><ul><li>Continuous infusion of </li></ul><ul><li>Bupivacaine 0.125% + Fentanyl 2-4  g/ml </li></ul><ul><li>Rate of 10-8 ml/hr </li></ul>
  19. 20. INDICATIONS FOR CONTINUOUS EPIDURAL ANALGESIA <ul><li>Pain 70.5% </li></ul><ul><li>Pregnancy induced hypertension 7.6% </li></ul><ul><li>Low birth weight 6.1% </li></ul><ul><li>Previous cesarean section 7.4% </li></ul><ul><li>Breech 4.8% </li></ul><ul><li>Twins 3.6% </li></ul>
  20. 21. STAGE OF LABOR <ul><li>Cervical dilatation (cm) % </li></ul><ul><li><3 11 </li></ul><ul><li>4-6 76.2 </li></ul><ul><li>7-10 12.8 </li></ul>
  21. 22. Trends of Pain Relief Method in Our Labor Ward (%) <ul><li>No analgesia 4% </li></ul><ul><li>Pethidine +Promethazine i.V. 12% </li></ul><ul><li>Continuous epidural analgesia 84% </li></ul>
  22. 23. Analgesia Satisfaction Rate Satisfactory pain relief 91% Incomplete analgesia 4% Unilateral analgesia 3% Without any pain relief 2%
  23. 24. MODE OF DELIVERY <ul><li>Spontaneous delivery 73.4% </li></ul><ul><li>Cesarean section 15.3% </li></ul><ul><li>Vacuum extraction 9% </li></ul><ul><li>Outlet forceps 2.3% </li></ul>
  24. 25. <ul><li>Apgar score At 1 min . At 5 min . </li></ul><ul><li>7-10 8186 8199 </li></ul><ul><li>4-6 142 131 </li></ul><ul><li>0-3 9 7 </li></ul><ul><li>TOTAL 8337 8337 </li></ul>Fetal Outcome
  25. 26. COMPLICATIONS <ul><li>Hypotension 112 </li></ul><ul><li>Headaches 32 </li></ul><ul><li>Paresthesia 5 </li></ul><ul><li>Backaches 6 </li></ul><ul><li>Total 155 </li></ul><ul><li>This is 2.3 % of all 6824 patients </li></ul>
  26. 27. Thank You !!! תודה !!!

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