Epidural Labour Analgesia(pain relief of child birth)

Dr Ashok Jadon,MD DNB MNAMS

Aesculap IPM FellowshipSenior Consultant & HOD AnaesthesiaTata Motors Hospital,Jamshedpur, India

Scope

Introduction & Need for labour Introduction & Need for labour analgesiaanalgesia

Pain PathwaysPain Pathways MethodsMethods Epidural analgesiaEpidural analgesia

– Walking epiduralWalking epidural– Our 3 yrs ExperienceOur 3 yrs Experience

Introduction & Need for labour Introduction & Need for labour analgesiaanalgesia

Pain undesirable experiencePain undesirable experience Labour painLabour pain

– IntenseIntense– Non-essential for progress of labourNon-essential for progress of labour– Undesirable side effects Undesirable side effects

on mother & Babyon mother & Baby

Most severe painMost severe pain

Effects of labour painEffects of labour pain

Management of Labour PainManagement of Labour Pain

Simplicity Simplicity Safety Safety Preservation of fetal homeostasisPreservation of fetal homeostasis

Gold Standard ; Epidural analgesia

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

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

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

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

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

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

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

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

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

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

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

COMPLICATIONS COMPLICATIONS

TOTAL SPINAL BLOCKADE TOTAL SPINAL BLOCKADE Dural puncture with inadvertent Dural puncture with inadvertent

subarachnoid injectionsubarachnoid injection

HYPOTENSION HYPOTENSION Normal preg women hypotension can be Normal preg women hypotension can be

prevented by rapid infusion of 500-prevented by rapid infusion of 500-1000ml of crystalloid solution 1000ml of crystalloid solution

– CENTRAL NERVOUS STIMULATION CENTRAL NERVOUS STIMULATION – MATERNAL PYREXIA MATERNAL PYREXIA

Mean temperature ↑ Mean temperature ↑ Significantly associated with neonatal Significantly associated with neonatal

sepsis evaluation and antibiotic therapy sepsis evaluation and antibiotic therapy Presence of pl inflammation Presence of pl inflammation Due to infection rather than the Due to infection rather than the

analgesia itself analgesia itself Pyrexia : associated with a higher Pyrexia : associated with a higher

incidence of IU infection from longer 1incidence of IU infection from longer 1stst stage labor stage labor

– BACK PAINBACK PAIN

EFFECT ON LABOREFFECT ON LABOR

– Epidural Epidural analgesia analgesia usually usually prolongs the 1prolongs the 1stst stage of labor, stage of labor, increases the increases the need for labor need for labor stimulation stimulation with oxytocinwith oxytocin

Epidural analgesiaEpidural analgesia

Did not significantly increase cesarean Did not significantly increase cesarean deliveries in either nulliparous or deliveries in either nulliparous or parous women in any individual trial or parous women in any individual trial or in their aggregatein their aggregate

TIMING OF EPIDURAL PALCEMENTTIMING OF EPIDURAL PALCEMENT

– No increase in either operative No increase in either operative vaginal delivery or cesarean vaginal delivery or cesarean delivery with early (≤3cm delivery with early (≤3cm dilatation) administration of dilatation) administration of epidural analgesia compared with epidural analgesia compared with later administration later administration

– Parkland Hospital : not begun prior Parkland Hospital : not begun prior to 3-5cm Cx dilatationto 3-5cm Cx dilatation

SAFETY SAFETY – 1968-1985, 26000 women : no maternal 1968-1985, 26000 women : no maternal

deaths deaths

CONTRAINDICATIONS CONTRAINDICATIONS – actual or anticipated serious actual or anticipated serious

maternal hemorrhage, infection at maternal hemorrhage, infection at or near the sites for puncture, or near the sites for puncture, suspicion of neurological disease suspicion of neurological disease

SEVERE PREECLAMPSIA-ECLAMPSIASEVERE PREECLAMPSIA-ECLAMPSIA

Ideal labor analgesia for women with Ideal labor analgesia for women with severe preeclampsia : controversial severe preeclampsia : controversial

Past two to three decades, most Past two to three decades, most obstetrical anesthesiologists : favor obstetrical anesthesiologists : favor epidural blockade for labor and delivery epidural blockade for labor and delivery in women with severe pre-ecalmpsia in women with severe pre-ecalmpsia

1995, Wallace and colleagues : GA and 1995, Wallace and colleagues : GA and RA are equally acceptable for cesarean RA are equally acceptable for cesarean delivery in women with severe pre-delivery in women with severe pre-ecalmpsiaecalmpsia

INTRAVENOUS FLUID PRELOADINGINTRAVENOUS FLUID PRELOADING

– Most authorities recommend prehydration, Most authorities recommend prehydration, usually with 500~1000ml of crystalloid usually with 500~1000ml of crystalloid solution solution

– Aggressive volume replacement in severe Aggressive volume replacement in severe preeclampsia women increases their risk preeclampsia women increases their risk for pul edema, especially in the first 72 hrs for pul edema, especially in the first 72 hrs postpartum postpartum

– No instances of pul edema in 738 women No instances of pul edema in 738 women in whom crystalloid preload was limited to in whom crystalloid preload was limited to 500ml500ml

EPIDURAL OPIATE ANALGESIAEPIDURAL OPIATE ANALGESIA

– Injection of opiates into the epidural Injection of opiates into the epidural space to relieve pain from labor space to relieve pain from labor become popular → rapid onset of become popular → rapid onset of pain relief, decrease in shevering, pain relief, decrease in shevering, less dense motor blockade less dense motor blockade

– Side effect : pruritus(80%), urinary Side effect : pruritus(80%), urinary retention(55%), N/V(45%), retention(55%), N/V(45%), headaches(10%)headaches(10%)

COMBINED SPINAL-EPIDURAL COMBINED SPINAL-EPIDURAL TECHNIQUESTECHNIQUES– No consensus regarding maternal Cx No consensus regarding maternal Cx

when comparing spinal or epidural when comparing spinal or epidural analgesia with combined techniquesanalgesia with combined techniques

– Parkland Hospital : 1223 women with Parkland Hospital : 1223 women with uncomplicated term preg (CSEA Vs IV uncomplicated term preg (CSEA Vs IV meperidine)meperidine)

Emergency c/sec for profound fetal Emergency c/sec for profound fetal tachycardiatachycardia

Fetal bradycardia occurred within 30min Fetal bradycardia occurred within 30min None of the cases responded to conservative None of the cases responded to conservative

measures measures Avoid the combined spinal-epiduralAvoid the combined spinal-epidural

Our techniqueOur technique

CSEA: 3 casesCSEA: 3 cases Epidural L2/ L3, Sitting/ lateralEpidural L2/ L3, Sitting/ lateral

– 12 ml 0.125% bupivacaine12 ml 0.125% bupivacaine– Infusion 0.08% (0.125% --0.0625%)Infusion 0.08% (0.125% --0.0625%)– No opioid ( Fentanyl, sufentanyl)No opioid ( Fentanyl, sufentanyl)– Breakthrough pain & Episiotomy Breakthrough pain & Episiotomy

0.125%- 0.25% bupivacaine0.125%- 0.25% bupivacaine

LSCS: 2% xylocaine with Adren. 15-LSCS: 2% xylocaine with Adren. 15-20ml20ml

Results..Results..

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

78%

Results..Results..

APGAR APGAR – Vaginal Del: 9.7 Vaginal Del: 9.7 ++ 0.64 0.64– Forceps: 9 Forceps: 9 ++ 1.3 1.3– LSCS: 8.1 LSCS: 8.1 ++ 1.8 1.8

Duration of labour (Min) 310 Duration of labour (Min) 310 ++ 143 143 Minimum: 25 minMinimum: 25 min Max: 12 hrsMax: 12 hrs

Results..Results..

SatisfactionSatisfaction– Highly satisfied: 72%Highly satisfied: 72%– Satisfied: 20%Satisfied: 20%– Not sure: 2%Not sure: 2%– Dissatisfied: 6% Dissatisfied: 6%

Catheter failure= 4 ( 4%) ( LSCS in both)Catheter failure= 4 ( 4%) ( LSCS in both) Dural Puncture= 2 (2%) ; No PDPHDural Puncture= 2 (2%) ; No PDPH Abnormal Paresthesia =2 (2%)Abnormal Paresthesia =2 (2%) Serious Complication= NilSerious Complication= Nil

92%

Our first patient; Our first patient;

Journey does not end here, we have to set new targets……..

Thank you very muchThank you very much