Epidural analgesia in labour. Soroka Medical Center Beer-ShevaIsrael2004

Introduction There is a substantial increase in the use of epidural analgesia during childbirth over the past two decades. There is a substantial increase in the use of epidural analgesia during childbirth over the past two decades. In the first stage of labour an epidural analgesia is required to block T8-L5 (T10-L1) and should include a block of S2-S4 in the second stage of labour. In the first stage of labour an epidural analgesia is required to block T8-L5 (T10-L1) and should include a block of S2-S4 in the second stage of labour.

Epidural analgesia is indicated in labour for: maternal distress as a result of painful uterine contractions maternal distress as a result of painful uterine contractions anaesthesia for a forceps delivery or vacuum extraction anaesthesia for a forceps delivery or vacuum extraction hypertension: pregnancy-induced and chronic. Epidural analgesia is helpful in lowering blood pressure as well as reducing the amount of sedation required hypertension: pregnancy-induced and chronic. Epidural analgesia is helpful in lowering blood pressure as well as reducing the amount of sedation required caesarian section caesarian section Pathological preliminary period and a discoordinated labour. Pathological preliminary period and a discoordinated labour.

The advantages are: It is very effective, although there is a some percent of a failure rateIt is very effective, although there is a some percent of a failure rate It provides enough analgesia for an instrumental delivery, episiotomy and can be used for operative deliveryIt provides enough analgesia for an instrumental delivery, episiotomy and can be used for operative delivery It is beneficial for the compromised fetus, eg in a breech deliveryIt is beneficial for the compromised fetus, eg in a breech delivery It has a good safety recordIt has a good safety record Facilitates patient cooperation during labor and delivery Facilitates patient cooperation during labor and delivery Avoids opioid-induced maternal and neonatal respiratory depression Avoids opioid-induced maternal and neonatal respiratory depression

The complications include: 1. Immediate complications 2. Delayed complications

Immediate complications Hypotension (systolic blood pressure <100 mmHg or a decrease of 25 percent below preblock average) due to loss of sympathetic tone Hypotension (systolic blood pressure <100 mmHg or a decrease of 25 percent below preblock average) due to loss of sympathetic tone Urinary retention Urinary retention Maternal convulsions or cardiovascular collapse after unintentional direct intravenous injection of a local anesthetic. Maternal convulsions or cardiovascular collapse after unintentional direct intravenous injection of a local anesthetic. Total spinal anesthesia following unintentional subarachnoid injection of local anesthetic. Total spinal anesthesia following unintentional subarachnoid injection of local anesthetic.

Delayed complications Postdural puncture headache Postdural puncture headache Transient backache Transient backache Epidural abscess or meningitis Epidural abscess or meningitis Permanent neurologic deficit Permanent neurologic deficit Epidural haematoma may develop secondary to a bloody tap Epidural haematoma may develop secondary to a bloody tap

The main contraindications: Patient refusal, Patient refusal, Maternal hemorrhage, Maternal hemorrhage, Coagulopathy Coagulopathy Maternal septicemia or untreated febrile illness Maternal septicemia or untreated febrile illness Infection at or near needle insertion site Infection at or near needle insertion site

Aortocaval compression may decrease uterine arterial pressure and increase uterine venous pressure. Consequently, uterine perfusion pressure (uterine arterial pressure minus uterine venous pressure) may be substantially reduced even in the presence of normal brachial arterial blood pressure Aortocaval compression may decrease uterine arterial pressure and increase uterine venous pressure. Consequently, uterine perfusion pressure (uterine arterial pressure minus uterine venous pressure) may be substantially reduced even in the presence of normal brachial arterial blood pressure

The dose of local anesthetic will depend on the intensity and location of the patient's pain, the amount and rate of cervical dilation; the strength, frequency and duration of uterine contractions; and the position of the fetal head at the time epidural analgesia is requested. The dose of local anesthetic will depend on the intensity and location of the patient's pain, the amount and rate of cervical dilation; the strength, frequency and duration of uterine contractions; and the position of the fetal head at the time epidural analgesia is requested.

Approximately 10 mL of to 0.25 percent bupivacaine (Marcaine) or to 0.25 percent ropivacaine (Naropin), with or without a small dose of a lipid-soluble opioid (e.g., fentanyl [Sublimaze] or sufentanil [Sufenta]), establishes effective analgesia with minimal motor block Approximately 10 mL of to 0.25 percent bupivacaine (Marcaine) or to 0.25 percent ropivacaine (Naropin), with or without a small dose of a lipid-soluble opioid (e.g., fentanyl [Sublimaze] or sufentanil [Sufenta]), establishes effective analgesia with minimal motor block

Maintenance of epidural analgesia may be achieved with: intermittent bolus injections, intermittent bolus injections, continuous epidural infusion continuous epidural infusion or patient-controlled epidural analgesia. or patient-controlled epidural analgesia. In most cases, analgesia may be maintained with a solution of local anesthetic more dilute than that used for induction. In most cases, analgesia may be maintained with a solution of local anesthetic more dilute than that used for induction.

Experience. In the Soroka Medical Center I looked after 7 cases of epidural analgesia in labour with the patient s medium age of 28.6 years (19-42), medium weight 67kg. (48- 82). Medium dilation of cervix was 4.3cm. (3-5cm.). The space of puncture was L2- L3,L3-L4. There was 1 case of blood in the cathether, and the cathether was plased into the another space. There were no significant decreese in maternaol blood pressure

Local anaesthetic agent used was marcaine 0.5%-0.25%-0.175% % with pethidine 2.5mg. per cc, introduced in bolus by 5-10 ml. As a test-dose was used lidocaine 2% 3ml in all of these cases. The efficacity was determined by a Vision Analog Score (VAS), which descended from 10-9 to 2-1 points. The mode of delivery was spontaneous in 5 cases and there where 2 cases of an Emergency Caesarean Section. Apgar Score was 8-10 points.

Final Comment The increased availability and effectiveness of epidural analgesia have altered the expectations of many women regarding intrapartum pain control. A significant number of parturients are requesting this form of analgesia for relief of labor pain. The risks and benefits of epidural analgesia, as well as other options for pain control, should be objectively presented to each woman well before the onset of labor. Careful patient evaluation, meticulous technique during epidural catheter placement and appropriate dosing of medication minimize the risk of serious complications from epidural analgesia. The increased availability and effectiveness of epidural analgesia have altered the expectations of many women regarding intrapartum pain control. A significant number of parturients are requesting this form of analgesia for relief of labor pain. The risks and benefits of epidural analgesia, as well as other options for pain control, should be objectively presented to each woman well before the onset of labor. Careful patient evaluation, meticulous technique during epidural catheter placement and appropriate dosing of medication minimize the risk of serious complications from epidural analgesia.

With the increasing popularity of labour analgesia there appeares a new problem: decreased or even absent maternal instinct at women, whose labour was anesthesiated.