Regional Analgesia Regional Analgesia and Anesthesia for and Anesthesia for Labor and DeliveryLabor and Delivery

Maj Islam Bano

MCPS,FCPS

Classified Gynaecologist

ObjectivesObjectives

Describe the pain pathways of labour and delivery

Describe labour analgesic techniques

Describe the complications of regional techniques

INTRODUCTIONINTRODUCTION

““If we could induce local If we could induce local anaesthesia withoutanaesthesia without

the absence of consciousness, the absence of consciousness, which occurswhich occurs

in general anaesthesia, many in general anaesthesia, many would see it aswould see it as

a still greater improvementa still greater improvement”.”.Sir James Young after the first maternal

death due to anaesthesia in England

1848

Dr. John Snow

born 15 March 1813 in York, England.Queen Victoria was given chloroform by John Snow for the birth of her eighth child and this did much to popularize the use of pain relief in labor.

Regional anesthetic techniques, were introduced to obstetrics in 1900, when Oskar Kreis described the use of spinal anesthesia.

Does Labor Pain Does Labor Pain Need AnalgesiaNeed Analgesia??

Analgesia for Labor and Analgesia for Labor and DeliveryDeliveryAlways controversial!

“Birth is a natural process”

Concerns for mother’s safety

Concerns for baby

Concerns for effects on labor

The Physiology of Pain in The Physiology of Pain in LaborLabor 11stst stage of labor stage of labor – mostly visceral

◦ Dilation of the cervix and distention of the lower uterine segment

◦ Dull, aching and poorly localized◦ Slow conducting, visceral C fibers, enter

spinal cord at T10 to L1 22ndnd stage of labor stage of labor – mostly somatic

◦ Distention of the pelvic floor, vagina and perineum

◦ Sharp, severe and well localized◦ Rapidly conducting A-delta fibers, enter

spinal cord at S2 to S4

Pain Pathways of LaborPain Pathways of Labor

Labor

Cardiovascular

Urinary

Neuro-endocrine

post-traumatic

stress syndrome

RespiratoryGastro-

intestinal

Potential effects of maternal hyperventilation and subsequent hypocarbia on oxygen delivery to the

fetus

What Are the Types What Are the Types of Labor Analgesiaof Labor Analgesia??

Goals of Labour Goals of Labour AnalgesiaAnalgesia

Dramatically reduce pain of laborShould allow parturient to

participate in birthing experienceMinimal motor block to allow

ambulationMinimal effects on fetusMinimal effects on progress of

labor

Types of Labor AnalgesiaTypes of Labor Analgesia

1. Non-pharmacological analgesia2. Pharmacological3. Regional Anesthesia/Analgesia

Regional Regional Anesthesia/AnalgesiaAnesthesia/Analgesia

Epidural SpinalCombined Spinal Epidural (CSE)Continuous spinal analgesia Paracervical blockLumbar sympathetic blockPudendal blockPerineal infiltration

Epidural AnalgesiaEpidural Analgesia Provides excellent pain relief reducing

maternal catecholaminesAbility to extend the duration of block

to match the duration of laborBlunts hemodynamic effects of uterine

contractions: beneficial for patients with preeclampsia.

Indications for LEAIndications for LEAPAIN EXPERIENCED BY A WOMAN IN PAIN EXPERIENCED BY A WOMAN IN

LABORLABORWhen medically beneficial to reduce

the stress of laborACOG and ASA stated

“ “ in the absence of a medical in the absence of a medical contraindication, maternal request is a contraindication, maternal request is a sufficient medical indication for pain sufficient medical indication for pain relief…”relief…”

Contraindications for LEAContraindications for LEAABSOLUTEABSOLUTE

Patients refusal Inability to

cooperate Increased

intracranial pressure Infection Severe

coagulopathy Severe hypovolemia Inadequate training

RELATIVERELATIVESystemic maternal

infectionPreexisting

neurological deficiency

Mild or isolated coagulation abnormalities

Relative (and correctable) hypovolemia

We are All Ready…Now We are All Ready…Now What? - Last CheckWhat? - Last CheckObstetrician is consulted and

confirmed LEAPreanesthetic evaluation is

performed/verifiedPt’s (and only patient’s) desire to

have LEA is reconfirmedPt’s understanding of risks of LEA

is reconfirmed

We are All Ready…Now We are All Ready…Now What? - Last CheckWhat? - Last Check

Fetal well-being is assessed and reassured

We are All Ready…Now We are All Ready…Now What? - Last CheckWhat? - Last Check

Supporting personal is available and present

We are All Ready…Now We are All Ready…Now What? - Last CheckWhat? - Last Check

Resuscitation equipment and drugs are immediately available in the area where LEA placed

Standard Technique of Standard Technique of LEALEA

1. Pre epidural check list is completed2. Aspiration prophylaxis 3. Intravenous hydration (what? When?

How?)4. Monitoring

◦ BP every 1 to 2 min for 20 min after injection of drugs

◦ Continuous maternal HR during induction ( e.g., pulse oximetry)

◦ Continuous FHR monitoring◦ Continual verbal communication

Standard Technique of Standard Technique of LEALEA

4. Maternal position ( sitting or lateral?)

Comparison of Sitting and Lateral Positions for Comparison of Sitting and Lateral Positions for Performing Spinal or Epidural ProcedureSPerforming Spinal or Epidural ProcedureS

Sitting Lying (left lateral)

Advantages• Midline easier to identify in obese women• Obese patients may find this position more comfortable

• Can be left unattended without risk of fainting.• No orthostatic hypotension• Uteroplacental blood flow not reduced (particularly important in the stressed fetus)

Disadvantages• Uteroplacental blood flow decreased• Orthostatic hypotension may occur• Increased risk of orthostatic hypotension if Entonox and pethidine have been administered• Assistant (or partner) needed to support patient

• May be more difficult to find the midline in obese patient

Spinal Spinal Anesthesia/AnalgesiaAnesthesia/Analgesia

Used mainly for very late in labor because it has limited duration of action

Faster onset than Epidural

Amount of local anesthetic used is much smaller

Searching For Balanced Searching For Balanced Labor AnalgesiaLabor Analgesia

Ambulatory Labor Ambulatory Labor AnalgesiaAnalgesia

(CSE)(CSE)

Combined spinal epidural Combined spinal epidural (CSE)(CSE)Initial reports: two interspace

technique-epidural followed by spinalLater evolution of CSE in the direction

of needle through needle techniquePostdural puncture headache: 1% or

less incidence for CSE with small bore atraumatic needles.

Advantages of CSE for Labor Advantages of CSE for Labor AnalgesiaAnalgesia

Rapid onset of intense analgesia (the patient loves you immediately!)

Ideal in late or rapidly progressing labor

Very low failure rate

Less need for supplemental boluses

Minimal motor block (“walking epidural”)

Espocan CSE Needle (B. Espocan CSE Needle (B. Braun)Braun)

Espocan CSE Needle (B. Espocan CSE Needle (B. Braun)Braun)

Maintenance of epidural analgesia Maintenance of epidural analgesia can be achieved by:can be achieved by:regular top-upsan epidural infusionpatient-controlled epidural analgesia (PCEA).

Intermittent bolus injectionsIntermittent bolus injections::

Bupivacaine: 0.125%-0.375%, 5-10 ml, duration:1-2 hr

Ropivacaine: 0.125%-0.25%, 5-10 ml, duration: 1-2 hr

Lidocaine: 0.75%-1.5%, 5-10 ml, duration: 1-1.5 hr

Continuous Infusion of Dilute Local Continuous Infusion of Dilute Local Anesthetic Plus OpioidAnesthetic Plus Opioid

Better pain relief while producing less motor block.

Maternal and neonatal drug concentrations safe.

Patient Controlled Epidural Analgesia Patient Controlled Epidural Analgesia (PCEA)(PCEA)

Advantages:Flexibility and benefit of self

administrationAbility to minimize drug dosageReduced demand on professional

timeDisadvantages:May provide uneven blockAddition of a basal infusion provides:More even block producing greater

patient satisfaction

Continuous Spinal Analgesia Continuous Spinal Analgesia Use of spinal microcatheters restricted

by FDA in 1992 due to reports of Cauda Equina Syndrome

28 or 32-G catheters for 22 or 26-G spinal needles

Ongoing multi-institutional study with FDA approval for evaluating the safety and efficacy of delivering sufentanil and/or bupivacaine via 28-G catheters

Continuous Spinal Analgesia Continuous Spinal Analgesia Results still preliminary but it appears

safe for labor analgesia and may offer some advantages

Some routinely use spinal macrocatheters through standard epidural needles for obese parturients or parturients with kyphoscoliosis

NEURAXIAL LABOR TECHNIQUESNEURAXIAL LABOR TECHNIQUES

LOCAL ANESTHETICSLOCAL ANESTHETICS

BupivacaineBupivacaineStandard local anaesthetic in

obstetricsHighly protein bound to α1-

glycoprotein and has a long duration of action, both of which minimize the fetal dose.

The maximum safe dose of bupivacaine is 3 mg/kg.

LevobupivacaineLevobupivacaineBinds to cardiac sodium channels

less intensely than dextrobupivacaine,

Less cardiotoxicity than bupivacaine.

LidocaineLidocaineMay not provide analgesia comparable

to bupivacaine, umbilical vein/ maternal vein ratio: twice than bupivacaine

Neuraxial OpioidsNeuraxial OpioidsThe following opioids have been used:Morphine, fentanyl, sufentanil,

meperidine, diamorphine.

Complications of Complications of Regional AnesthesiaRegional Anesthesia

Complications of regional Complications of regional anesthesiaanesthesia

Post Dural Puncture Headache Post Dural Puncture Headache (PDPH)(PDPH)

severe, disabling fronto-occipital headache with radiation to the neck and shoulders.

present 12 hours or more after the dural puncture

worsens on sitting and standingrelieved by lying down and

abdominal compression.

Complications of regional Complications of regional anesthesiaanesthesia

PDPH syndromePDPH syndrome1. Photophobia2. Nausea3. Vomiting4. Neck stiffness5. Tinnitus6. Diplopia7. Dizziness

Complications of regional Complications of regional anesthesiaanesthesia

Differential diagnosis of post-dural Differential diagnosis of post-dural puncturepuncture

headache in the obstetric patient:headache in the obstetric patient:11. Non-specific headache2. Caffeine-withdrawal headache3. Migraine4. Meningitis5. Sinus headache6. Pre-eclampsia7. Drugs (amphetamine, cocaine)8. Pneumocephalus-related headache9. Intracranial pathology (hemorrhage,

venous thrombosis)

Complications of regional Complications of regional anesthesiaanesthesia

Management of PDPHManagement of PDPHConservative:Conservative:Bed restEncourage oral fluids and/or

intravenous hydrationCaffeine - either i.v. (e.g. 500mg

caffeine in 1litre of saline) or orally

Regular AnalgesiaReassurance

Complications of regional Complications of regional anesthesiaanesthesia

Management of PDPHManagement of PDPHOthersOthers1. Theophylline3. Sumatriptan4. Epidural saline5. Epidural dextran6. Subarachnoid catheter7. Epidural blood patch

Complications of regional Complications of regional anesthesiaanesthesiaThe new method of prevention of post-The new method of prevention of post-dura puncture headache (maintaining CSF dura puncture headache (maintaining CSF volume):volume):1. Injecting the CSF in the glass syringe back into thesubarachnoid space through the epidural needle2. Passing the epidural catheter through the dural hole into the subarachnoid space3. Injecting of 3-5 ml of preservative free saline into the subarachnoid space through the intrathecal catheter4.Administering bolus and then continuous intrathecal labor analgesia through the intrathecal catheter5. Leaving the subarachnoid catheter in-situ for a total of 12-20 h

Complications of regional Complications of regional anesthesiaanesthesia

Cardiovascular complicationsCardiovascular complicationsHypotension (can lead to cord

ischaemia)Bradycardia

Effects on the course of labour and Effects on the course of labour and on the fetuson the fetus

Effect of epidural analgesia on the Effect of epidural analgesia on the progress and outcome of labourprogress and outcome of labour

The recently published guidelines on intrapartum care by the UK national institute of health and clinical excellence indicate that epidural analgesia is:

Not associated with a longer first stage of labour or an increased chance of a caesarean birth

Associated with a longer second stage of labour and an increased chance of an instrumental birth.

Complications of regional Complications of regional anesthesiaanesthesia

Neurological complicationsNeurological complicationsNeedle damage to spinal cord,

cauda equina or nerve roots.Spinal haematomaSpinal abscessMeningitis and ArachnoiditisNeurotoxicity

Complications of regional Complications of regional anesthesiaanesthesia

MiscellaneousMiscellaneousVenous puncture e.g. of dural veinsCatheter breakageExtensive block (including

unplanned blocks)ShiveringBackache - Long-term backache is

not a complication of neuraxial techniques.

Complications of regional Complications of regional anesthesiaanesthesia

Drug side effectsDrug side effectsNausea and vomiting (opiates)Respiratory depression (opiates)AnaphylaxisToxicity (including intravascular

injection of local anaesthetics)

ConclusionConclusion

“The delivery of the infant into the The delivery of the infant into the arms of a conscious and pain-free arms of a conscious and pain-free

mother is one of the most mother is one of the most exciting and rewarding moments exciting and rewarding moments

in medicine.”in medicine.”

Moir DD. Extradural analgesia for Moir DD. Extradural analgesia for caesarean section. Br J Anaesth 1979; caesarean section. Br J Anaesth 1979;

51: 1093. 51: 1093.