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Epidural Analgesia In Labour Indications, Various techniques its advantages and Contraindications
ANATOMICAL CONSIDERATION - May result in unnecessary septic work up investigations for the newborn Lumbar epidural analgesia Complications - Headache - backache - Haemorrhage - Respiratory depression - Retention of urine - Infection - Fetal depression from local anaesthetics - total spinal block - Convulsions*induced by local anesthetic - Cardiac arrest*induced by local anesthetic - Epidural abscess or meningitis* - Permanent neurological deficit* is very rare Combined spinal epidural anesthesia. - Also known as needle through a needle technique - Introduced in the 80’s - Epidural needle inserted, followed by 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needle is introduced through it into the subarachnoid space and an opioid or local anesthetic is injected, needle then withdrawn and epidural catheter inserted for top up doses when needed.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 to cover the first stage of labor - For the second stage of labor a local anesthetic is required - A mixture of sufentanil with bupivacaine is given to cover early and late stages of labor with mild motor block, faster labor and less instrumental delivery rate Why combined procedure is better than epidural? - More rapid onset - The anesthetic blood level is less in maternal and fetal serum - More intense motor block for c/s - Asserting the position of the epidural catheter - Allows extension of sensory level or duration of spinal block; for a trial of forceps to c/s. - The use of different agents later on in the post- operative period; pain relief is possible. Combined spinal epidural - Confirming the site of epidural catheter decreases the risks of dural puncture - Not suitable for patient; 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 - Hypotension; due to sympathetic block. Which Is Treated By Uterine Displacement, Hydration And Ephedrine (10-15 Mg) I.V.? - Total spinal block; due to overdose. Symptoms include hypotension, apnea and cardiac arrest!!! - Spinal post puncture headache; it occurs in 1.5% of cases if the gauge 22-24 needle used. A result from 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; resulting from CSF hypotension - Bladder dysfunction - Hypertension with oxytocics used postpartum is seen more commonly in females who received regional anesthesia - Arachnoiditis & meningitis; it used to occur due to preservatives found in anesthetics; nowadays, a rarity.  How epidural Affect labor and delivery - No effect on the conduct of labor - Increase the rate of instrumental delivery. - Prolongation of second stage; allow the fetal head to proceed and crown spontaneously without necessitating bearing down provided fetal heart monitoring is reassuring. - Rate 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 result in obstructed labor and requires intervention. - When full dilatation allowed fetal head to descend, rotate and flex without undue bearing down. - Remember mothers can’t feel the pushing to so allow the head to push down against the pelvic floor to be delivered - Keep in mind!!!!! Crowning needs time; allow 3 hrs in primigravidas and 2hrs in multgravidas as long as the fetal heart is “ok” How to avoid instrumental delivery - Try not to give top up doses after full dilatation (at the expense of feeling pain in second stage) - Limit the dose given of the local anesthetic close to the end of the first stage - Avoid the urge to crowning the patient, as soon as she reaches full dilatation. Allow spontaneous descent of the head  - There’s no difference (as shown in studies) 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; - make sure that there are good effective uterine contractions - Encourage mother to push with uterine contractions - Selective epidural block of the lower thoracic segments only which also covers perineal sensation whilst preserving pelvic floor muscle tone - Caudal and lumbar epidural effect leads to absent or diminished bearing down reflex thus increased rate of instrumental delivery - Give a segmental epidural at the level of t10-t12 that pertains to the bearing down reflex - If you give analgesics with the anesthetic, you will decrease the dose of the anesthetic used thus the motor block,and its side effects are decreased Pregnancy | Pregnancy Month by Month Location
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