This document discusses epidural analgesia for pain relief during labor and childbirth. It provides details on how epidurals are administered, possible complications, effects on labor and delivery outcomes, and the author's experience with over 250 cases at their hospital. Their results showed high mother satisfaction rates, few complications, and no serious issues. The author concludes that their technique for epidural administration was successful and safe based on their initial experience.

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. Scope Introduction & Need for labour analgesia Pain Pathways Methods Epidural analgesia Walking epidural Our 3 yrs Experience

3. Introduction & Need for labour analgesia Pain undesirable experience Labour pain Intense Non-essential for progress of labour Undesirable side effects on mother & Baby

4. Most severe pain

6. Effects of labour pain

7. Management of Labour Pain

10. Simplicity Safety Preservation of fetal homeostasis Gold Standard ; Epidural analgesia

11. Before starting to insert the epidural, an intravenous drip is put in place.

12. Epidurals are inserted using a sterile technique, with the anaesthetist wearing a sterile gown and gloves.

13. The patient’s back is washed with an antiseptic solution and then a sterile drape is placed over the area.

14. Local anaesthetic is injected into the skin over the spine, to numb the area where the epidural is to be inserted.

15. A fine plastic tube (epidural catheter) is threaded through the needle.

16. The anaesthetist removes the epidural needle, leaving the epidural catheter in place.

17. A special connector is attached to the epidural catheter to allow more local anaesthetic to be given.

18. Further doses of local anaesthetic may given through the filter and connector either manually or using an electronic pump.

19. The epidural catheter is held in place by tape.

21. An epidural may provide good pain relief for the duration of labour.

22. Thanks to Heidi and John for permission to use their photos.

24. 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

25. 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

26. EFFECT ON LABOR Epidural analgesia usually prolongs the 1 st stage of labor, increases the need for labor stimulation with oxytocin

27. Epidural analgesia Did not significantly increase cesarean deliveries in either nulliparous or parous women in any individual trial or in their aggregate

28. 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

29. 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

30. 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

31. 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

32. 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%)

33. 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

34. 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

35. Results.. Number of case =250 Vaginal Deliveries: (56%) Forceps application:(22%) LSCS : (22%) 78%

36. 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

37. 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%

38. Our first patient;

39. Journey does not end here, we have to set new targets…….. Thank you very much