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Pain
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Pre-eclamptic toxaemia
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High risk fetus group
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Breech delivery/ twin delivery
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Trial of prolonged labour
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Patient request
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Symptomatic heart disease
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Respiratory disease
- Cerebrovascular disease
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Abnormal or dead fetus
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Inco-ordinate uterine action
Prerequisites for epidural
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Maternal consent
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Maternal /fetal status
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Progress of labor
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Nursing
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IV bolus
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Monitor B/P
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Continuous fetal monitoring
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Catheter
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Safety
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Muscle weakness
Epidural Analgesia
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Most effective form of pain relief for labor.
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Combination of opioids with low concentrations of local anesthetics
provide effective analgesia whilst reducing some of the unwanted side
effects such as motor block
Advantages of Extradural analgesia over subarachnoid block
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Incidence and magnitude of maternal arterial hypotension is less
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Risk of post puncture headache and serious neurological sequel is less
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Theoretically it is safer to use the continuous technique in the
extradural space than in the subarchnoid space
Various techniques of Extradural analgesia -
Lumbar epidural block
1. Standard block T10 to S5
---A - Single Dose
---B - Continuous Technique : Repeated Injection Through Catheter
2. Continuous segmental block,
---A - Initially Segmental T10 To L1 Block
---B - In Second Stage Extended To Sacral Segments -
Caudal block
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Single dose
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Continuous technique
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Double catheter technique
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Upper catheter for segmental block
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Lower catheter for sacral block
Advantages of Epidural Analgesia
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Provides superior pain relief during first and second stages of labor.
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Facilitates patient cooperation during labor and delivery.
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Provides anesthesia for episiotomy or forceps delivery
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Allows extension of anesthesia for cesarean delivery.
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Avoids opioid -induced maternal and neonatal respiratory depression
How does the epidural anesthesia work ?
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An epidural anesthetic blocks the nerve roots that lead to the uterus and
lower part of the body. The roots are located in a space near the spinal
cord (epidural space). This lies within the spine just outside the outer
covering of the spinal cord. Epidural Block
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Continuous block
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Placed between Dura mater and ligamentum flavum
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Does not enter CSF space
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Give bolus- observe for hypotension
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Change position frequently
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If narcotics are used respiratory depression can result
Contraindication to epidural analgesia
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-Patient refusal
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-Active maternal hemorrhage
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-Maternal septicemia or untreated febrile illness
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-Infection at or near needle insertion site
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-Maternal coagulopathy (inherited or acquired)
Anatomy of epidural space
POSITIONING THE PATIENT TO APPLY EPIDURAL CATHETER
Epidural Procedure carried out by Dr. Najeeb Layyous in 1982
ANATOMICAL CONSIDERATION
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PAIN IN EARLY 1st STAGE :- T10 – Ll
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PAIN IN LATE 1st STAGE AND IN 2nd STAGE :- T10 - Ll AND S2 - S4
Physiology of labor pain(1st. stage
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Distention of the lower uterine segment,
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Mechanical dilatation of the cervix
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And due to stretching of excitatory nociceptive afferents resulting from
the contraction of the uterine muscles.
Timing Consideration for epidural block
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Cervical dilation 3-5cm.
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Diagnosis of active labor has been established and the patient has begun
to request pain relief.
Epidural anesthetic agents
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- The most commonly used drugs are lidocaine 1 – 2 % for short or
intermediate action .
- Bupivacaine 0.25 - 0.75 % for long action . Ropivacine 0.2 – 1.0 % for long
action .
Epidural anesthetic agents
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The adult dose 1 -2 ml / segment bolus for anesthesia, this dose decreases
with pregnancy and age, increases with height. - 1/3 or 1/2 of the initial
dose can be re- injected when needed. - Test dose (3-5 ml) must be injected
first to be sure of the proper space. - Opioids (morphine 2 -5 mg, fentanyl
0.05 – 0.1mg( can be added to local anesthetic drugs for epidural
anesthesia.
Complications of epidural analgesia
Immediate
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Hypotension (systolic blood pressure <100 mm Hg or a decrease of 25
percent below pre-block average)
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Urinary retention
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Local anesthetic induced convulsions*
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Local anesthetic induced cardiac arrest*
Delayed
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Postural puncture headache
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Transient backache
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Epidural abscess or meningitis*
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Permanent neurological deficit* is very rare
- Epidural abcesses; extremely rare
Complications of epidural
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Hypotension ;
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May lead to fetal distress and if not corrected within 3minutes may lead
to neurological sequalae and low APGAR
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Fever ;
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May lead to unnecessary septic work up investigations for the newborn
Complications of lumbar epidural analgesia
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Headache - backache
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Haemorrhage
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Respiratory depression
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Retention of urine
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Infection
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Fetal depression from local anaesthetics - total spinal block
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Local anesthetic induced convulsions*
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Local anesthetic induced cardiac arrest*
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Epidural abscess or meningitis*
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Permanent neurological deficit* is very rare
Combined spinal epidural anesthesia
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Also known as needle through needle technique
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Introduced in the 80’s
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Epidural needle inserted, then a spinal needle is introduced through it
into the subarachnoid space and an opioid or local anesthetic is injected,
needle then withdrawn and epidural catheter inserted for top up doses when
needed. -
Opioids given intrathecally or epidurally cover the first stage of labor
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A local anesthetic is required for the second stage of labor
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A mixture of sufentanil with bupivacaine is given to cover early and late
stages of labor with minimal motor block, faster labor and less instrumental
delivery rate
Advantages of combined procedure over epidural
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More rapid onset
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Less blood level of the anesthetic in maternal and fetal serum
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More intense motor block for c/s
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Confirms the position of the epidural catheter
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Allows extension of sensory levelor duration ofspinal block; for a trial
of forceps to c/s.
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Allows use of different agents later on in the post operative period; pain
relief
Combined spinal epidural
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Decreases the risks of dural puncture by confirming the site of epidural
catheter
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Not suitable for every parturient; if labor progresses rapidly this leaves
the epidural catheter untested should an emergency rise requiring its
immediate use for a c/s
Spinal anesthesia complications
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Hypotension; due to sympathetic block. This Is Treated By Uterine Displacement,
Hydration And Ephedrine (10-15 Mg) I.V.
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Total spinal block; due to overdose. Manifested by hypotension, apnea and
cardiac arrest!!! -
Spinal post puncture headache; occurs in 1.5% of cases if gauge 22-24
needle used. It is caused by CSF leak and prevented by using small gauge
needles; placing the woman flat on her back for several hours post-
procedure and avoiding multiple punctures. -
Convulsions; usually due to CSF hypotension
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Bladder dysfunction
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Hypertension with oxytocics used postpartum is seen more commonly in
females who received regional anesthesia
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Arachnoiditis and meningitis; used to occur due to preservatives found in
anesthetics; nowadays a rarity.
Effect of epidural on labor and delivery
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No effect on the conduct of labor
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The rate of instrumental delivery appears to be increased
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Prolonged second stage; allow the fetal head to proceed and crown
spontaneously without necessitating bearing down provided fetal heart
monitoring is reassuring -
Incidence of malposition and malpresentation are increased with epidural
due to the decreased tone of the pelvic floor muscles and subsequently
malrotation of fetal head and increased incidence of deep transverse arrest -
Early bearing down will result in obstructed labor and requires
intervention
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When full dilatation allow fetal head to descend, rotate and flex without
undue bearing down. -
Remember mom can’t feel the pushing so allow the head to push down against
the pelvic floor to be delivered
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Remember!!!!! Crowning needs time; allow 3 hrs in primi’s and 2hrs in
multi’s as long as the fetal heart is “ok”
How to avoid instrumental delivery
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Avoid giving top up doses after full dilatation (at the expense of feeling
pain in second stage)
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Limit the dose of the local anesthetic given close to the end of the first
stage
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Avoid the urge to crowning the patient as soon as she is fully dilated.
Allow spontaneous descent of the head -
Studies done have shown that there’s no difference in the apgar scores
amongst those who are allowed delivery without urging to push down early and
those who deliver via instrumental delivery early after full dilatation -
Active management of the second stage of labor;
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Ensure good effective uterine contractions
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Encourage mom to push with uterine contractions
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Selective epidural block of the lower thoracic segments only which also
covers perineal sensation whilst preserving pelvic floor muscle tone -
The effect of caudal and lumbar epidural leads to absent or diminished
bearing down reflex thus increased rate of instrumental delivery
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Giving segmental epidural at the level of t10-t12 pertains the bearing
down reflex -
Giving analgesics with the anesthetic decreases the dose of the anesthetic
used thus the motor block and its side effects are decreased
