Download LABOR ANALGESIA: AN UPDATE

LABOR ANALGESIA: AN
UPDATE
DR. FATMA AL DAMMAS
CONSULTANT
OBSTETRIC ANAESTHESIA AND PAIN
DEPARTMENT OF ANAESTHSIOLOGY
KING KHALID UNIVERSITY HOSPITAL
RIYADH.
LABOR ANALGESIA: AN
UPDATE
IS THERE AN ADVANTAGE OF
CSE OVER EPIDURAL?
DR. FATMA AL DAMMAS
CONSULTANT
OBSTETRIC ANAESTHESIA AND PAIN
DEPARTMENT OF ANAESTHSIOLOGY
KING KHALID UNIVERSITY HOSPITAL
RIYADH.
FROM THE HOLY QURAN
IN THE NAME OF ALLAH THE MOST
BENEFICIENT THE MOST MERCIFUL
“AND THE PAINS OF CHILDBIRTH DROVE
HER TO THE TRUNK OF A DATE PALM.
SHE SAID “ WOULD THAT I HAD DIED
BEFORE THIS, AND HAD BEEN
FORGOTTEN AND OUT OF SIGHT”.
SURAH 19: 23 (SURAH MARYAM)
CONTENTS
• Introduction
• CSE
• Epidural analgesia
• Review articles
Stages of Labour
Pain pathways during labor
INTRODUCTION
• There are many different techniques, both
regional and non-regional to provide labour
analgesia.
• Non-regional techniques are the most frequently
employed methods for labour analgesia.
• Meperidine (pethidine) is the most frequently used
opioid for labour analgesia. Its limited efficacy and
side effects are well documented.
INTRODUCTION
• Inhalation of nitrous oxide relieves labour pain to
a significant degree .
• Epidural analgesia, CSA , PCEA ,when compared
with other methods, provides superior analgesia
for labour.
IDEAL Labour Analgesia
 Safe (mother, fetus)
 Composure, Control (Pain, Pain Relief)
 Ease of Administration
 Rapid, Profound, Consistent Analgesia
(Stage I & II)
 No Effect:
Ambulation
Maternal Expulsive Efforts
Progress of Labour
Facilitate Surgical Anesthesia avoiding GA
CSE
LEA
CSE ADVANTAGES
 Rapid Onset IT Component
 Better Blocks
 IT Medications Devoid of Motor Blockade
“Walking Epidural”
 Atraumatic Spinal Needles (fewer PDPH?).
 Epidural Catheter for Supplemental Analgesia.
 Epidural Catheter for Surgical Anesthesia.
CSE ADVANTAGES
 Rapid Onset IT Component
 Better Blocks
 IT Medications Devoid of Motor Blockade
“Walking Epidural”
 Atraumatic Spinal Needles (fewer PDPH?).
 Epidural Catheter for Supplemental Analgesia.
 Epidural Catheter for Surgical Anesthesia.
Rapid Onset of Analgesia
• Most dramatic feature; analgesia is often nearly
complete before the epidural cath. is taped up
and the tray discarded
Rapid Onset of Analgesia
• Van de Velde randomized 110 parturients to epid.
BUP 0.125% w sufentanil and epinephrine or IT
sufentanil.
• The time to effective analgesia was significantly
shorter in the CSE group.
Van de Velde M: CSA in labor. Anesthesiology 2000 ;92:869-70
Rapid Onset of Analgesia
• Nickells randomized women to epid. or SA BUP and
fentanyl. The time to first painless contraction was shorter
in the CSE group ( 10 ± 5.7 vs. 12.1 ± 6.5min)
• Hepner randomized women to receive 10ml of 0.0625%
BUP + fentanyl 2mcg/ml + epinephrine + bicarbonate
epidurally or 25mcg fentanyl and 2.5mg BUP IT
– 26/26 patients had a VAS < 3 within 5min in CSE
group, only 17/24 in the epidural group
Does a few minutes advantage in
analgesic onset matter?
CSE ADVANTAGES
 Rapid Onset IT Component
 Better Blocks
 IT Medications Devoid of Motor Blockade
“Walking Epidural”
 Atraumatic Spinal Needles (fewer PDPH?).
 Epidural Catheter for Supplemental Analgesia.
 Epidural Catheter for Surgical Anesthesia.
Better Blocks
• Quality of analgesia is improved by CSE
• Norris retrospectively compared epid. and CSE
techniques in 1661 women who received either
technique and found a lower incidence of failed blocks
and a greater incidence of bilateral symmetrical
analgesia w CSE.
Norris MC .Anesth Analg 1995;79:529-37
Better Blocks
 CSE cannot be obtained using the needle-throughneedle technique unless the epid needle is positioned
near the mid line of the actual epid space.
 There may be passage of LA from the epidural space
into the IT space via the dural hole.
 There may be synergism between epid and spinal
blocks, such that one enhances the other.
CSE ADVANTAGES
 Rapid Onset IT Component
 Better Blocks
 IT Medications Devoid of Motor Blockade
“Walking Epidural”
 Atraumatic Spinal Needles (fewer PDPH?).
 Epidural Catheter for Supplemental Analgesia.
 Epidural Catheter for Surgical Anesthesia.
Less Motor Block
• CSE associated with less total LA use for a given degree
of analgesia
• In a randomized trial, Collis found 12/98 patients in the
CSE group, compared to 32/99 in the epid group had leg
weakness at 20min.
• Requirements for anesthesiologist intervention are lower
w CSE regardless of technique.
Collis RE. Davies DWL. Aveling W. Randomised comparison of CSE and
standard epidural in labour Lancet 1995, 345.4 3-6.
Protocol for Ambulation
• • A patient must remain at bed rest for at least 30 minutes
following initiation of CSE.
• • Prior to ambulation, approval must be obtained from the
labor nurse, obstetrician, and anesthesiologist. FHR
tracing must be within normal limits prior to ambulation.
• • Ambulation is allowed only after the patient has been
examined by the anesthesiologist to rule out motor block.
• • A BP measurement taken immediately prior to
ambulation while the patient is upright.
Protocol for Ambulation
• • Ambulating parturients must be supported on one side
by a companion and by an iv pole (with wheels) for
support on their other side.
• • If a parturient does not wish to ambulate but wants to
get out of bed, (or for patients who need to have
continuous FHR monitoring), they may be assisted out
of bed into the rocking chair adjacent to the bed.
First steps to
painless
Motherhood!
Less Motor Block
• Adding opioids < MB
• “Walking” epidurals: < MB meant better
outcomes
– No evidence of improved labor
pattern/outcome with ambulation !!!.
– Women don’t walk even if they can.
– Monitoring problems.
– Techniques that allow “walking” may be
“better” whether
or not patient
ambulates.
Davies: Anesthesiology
2002
Pregnant control
• Updated
Computerised
posturography
dynamic
• Assessing
relative
contributing
somatosensory, visual, vestibular input
to maintain accurate balance
• Walk / walk & turn test
• Step up & standing up from sitting
After labour CSE
Intrathecal Bupivacaine and Sufentanil for Ambulatory Labor Analgesia:
Effect of Dose Reductions
Schultz R, Campbell DC, et al. Anesth’logy (SOAP suppl) A18, 1998
100
90
80
70
S 10 + B 2.5
VAS 60
PAIN
50
S 5 + B 1.25
*
40
*
30
20
*
*
10
* P < 0.05
*
0
0
5
10
15
30
45
Time (min)
60
75
90
105
120
Does a Walking” epidurals meant
better in analgesic outcomes?
CSE ADVANTAGES
 Rapid Onset IT Component
 Better Blocks
 IT Medications Devoid of Motor Blockade
“Walking Epidural”
 Atraumatic Spinal Needles (fewer PDPH?).
 Epidural Catheter for Supplemental Analgesia.
 Epidural Catheter for Surgical Anesthesia.
CSE ADVANTAGES
PDPH
– Rate ~ 1%
– CSE technique might actually decrease the
incidence of dural puncture with the epid needle
by allowing the anesthesiologist to confirm an
equivocal loss of resistance by passage of a
pencil point spinal needle rather than advancing
the large bore epid needle further.
CSE ADVANTAGES
• The use of small bore “atraumatic” spinal needles will
reduce the incidence of PDPH in patients receiving CSE .
• Possible explanation for this finding is that, the spinal
needle may be used for verification of correct placement
of the epidural needle when there is inconclusive loss of
resistance
David J. Birnbach MD ;Advances in labour analgesia . CAN J ANESTH
2004 51: 6
↓ PDPH has advantage over analgesia ?
CSE ADVANTAGES
Rapid Onset IT Component
IT Medications Devoid of Motor Blockade “Walking
Epidural”
Atraumatic Spinal Needles (fewer PDPH?).
Epidural Catheter for Supplemental Analgesia.
Epidural Catheter for Surgical Anesthesia.
Better Patient Satisfaction
An Updated Report by the American Society of
Anesthesiologists Task Force on Obstetric Anesthesia
Anesthesiology 2007; 106:843–63
• Several studies have found better patient satisfaction
scores with CSE vs. conventional epid.
• Others have found no difference, but none have found
better satisfaction with conventional epid analgesia
Better in Difficult Backs
• An Updated Report by the American Society
Anesthesiologists Task Force on Obstetric Anesthesia
Anesthesiology 2007; 106:843–63
of
• CSE has been associated with improved chances of
adequate analgesia in parturients with scoliosis or other
causes of a difficult back.
Progress of Labor
• Studies have compared obstetric outcomes associated with
CSE and epidural labor analgesia.
• Tsen et al. reported faster initial cervical dilation and shorter
time from induction of analgesia to full cervical dilation
among women receiving CSE analgesia vs epidural
analgesia.
Tsen L.C,Thue BDatta S: Anesthesiology 2001;91;920-5
Progress of Labor
• Tow large randomized trials have confirmed an increase in
the spontaneous vaginal delivery rate with CSE vs.
conventional epid analgesia.
Progress of Labor
• The pain relief leads to a decrease in the output of the
sympathetic nervous system. There is a significant
decrease in the level of circulating epinephrine after the
induction of labour analgesia.
• Epinephrine is a tocolytic.
• A decrease in epinephrine will cause an increase in
uterine tone
P. D. W. Fettes, C. S. Moore1 analgesia during labour British Journal
of Anaesthesia July 18, 2006 97 (3): 359–64
Other advantage
• A retrospective analysis involving near 20,000 patients
found incidences of overall failure, IV epid cath, wet tap,
inadequate epid analgesia and cath replacement were
all lower in patients receiving CSE.
• Sacral analgesia is difficult to obtain with conventional
epidural, CSE is good at providing it.
• CSE is an obvious choice in advanced labor.
Do a few advantages in CSE analgesia
matter?
CSE Complications
• Fetal bradycardia/FHR changes
• Pruritus
• Infection
• Neurotrauma
• Other side effects
Fetal
Heart
Rate
Post-CSE NRFHR:
FETAL BRADYCARDIA
1993 Cohen Anesth Analg
1994 Clark Anesth’logy
1997 Campbell DC Anesth’logy
1998 Gambling Anesth’logy
1999 Palmer Anesth Analg
2000 Wong Anesth’logy
2001 Van de Velde Reg An Pain Man
* 50% greater than Epidural
15% (11/73)
30% (9/30)
15% (6/39)
18% (72/400)
12% (12/100) *
17% (28/67)
11% (40/351) *
How does labour analgesia cause fetal
bradycardia?
FETAL BRADYCARDIA
1. The pain relief leads to a decrease in the output of the
sympathetic nervous system. There is a significant
decrease in the level of circulating epinephrine after the
induction of labour analgesia.
2. Epinephrine is a tocolytic. A decrease in epinephrine will
cause an increase in uterine tone.
3. Increased uterine tone will decrease placental blood flow.
4. If placental blood flow is decreased significantly there will
be a subsequent fetal bradycardia.
• Edward T. Riley MDCAN J ANESTH 2003 / 50: 6 / pp R1–R3
FETAL BRADYCARDIA
1. Pain relief leads to a decrease in blood pressure.
2. The decrease in blood pressure, norepinephrine
levels increase.
3. This will lead to uterine artery constriction.
4. Uterine artery vasoconstriction will decrease placental
blood flow.
5. If placental blood flow is decreased significantly there
will be a subsequent fetal bradycardia.
Edward T. Riley MDCAN J ANESTH 2003 / 50: 6 / pp R1–R3
FETAL BRADYCARDIA
Rapid onset pain relief may cause
temporary norepinephrine predominance
Norepinephrine
- effects
uterine tonus 
uterine
contractions 
Epinephrine
- effects
uterine tonus 
uterine contractions 
FETAL BRADYCARDIA
Several studies found no increased incidence
of fetal heart rate abnormalities or increased
Caesarean section rate ~ CSE*
* Nielsen
PE et al. Anesth Analg 1996; 83:742-746
Albright GA et al. Reg Anesth 1997; 22:400-405
Eberle RL et al. Am J Obstet Gynecol 1998; 179:155-159
Palmer CM et al. Anesth Analg 1999; 88:577-581
Norris MC et al. Anesthesiology 2001; 95:913-920
CSE Complications
• Fetal bradycardia/FHR changes
• Pruritus
• Infection
• Neurotrauma
• Other side effects
Norris MC, et al. Anesth Analg 79:529-37, 1994
Complications of Labor Analgesia: Epidural versus
Combined Spinal Epidural Techniques
Pruritus
LEA (n=388)
1.3 %
CSE (n=536)
41.3 %
CSE Complications
• Fetal bradycardia/FHR changes
• Pruritus
• Infection
• Neurotrauma
• Other side effects
Infection
• There are least 8 case reports of spinal meningitis
related to a CSE.
• Too many instrumentations- Too many cooks spoil a
broth?
• There is also a case report of epid abscess after a CSE
for labor.
• Conversely spinal anesthesia for elective CS does not
carry these risks.
CSE Complications
• Fetal bradycardia/FHR changes
• Pruritus
• Infection
• Neurotrauma
• Other side effects
Neurotrauma
• Cord trauma has been reported with the CSE technique in
at least in 5 cases.
• In a report of 7 cases with damage to the conus
medullaris following spinal anesthesia by Reynolds of
Saint Thomas Hospital in London, 4 were patients who
had received a CSE and 3 after a single shot spinal.
• In all cases, an atraumatic needle was used, 25 or 27
gauge Whitacre and the anesthesiologist believed to be at
L2-3.
• Van Gessel et al. demonstrated that 59% of dural
punctures were performed 1 or 2 spaces higher than
assumed.
• Broadbent et al. demonstrated in a group of experienced
anesthesiologists that when they believed they were at L3L4, in 85% of the cases the space was 1 to as many as 4
segments higher.
CSE Complications
• Fetal bradycardia/FHR changes
• Pruritus
• Infection
• Neurotrauma
• Other side effects
Complications of Labor Analgesia: Epidural versus
Combined Spinal Epidural Techniques Norris MC, et al.
Anesth Analg 79:529-37, 1994
LEA (n=388)
Nausea
Vomiting
Hypotension
1.0 %
1.0 %
< 10.0 %
Dural Puncture
Blood Patch
4.2 %
4
CSE (n=536)
2.4 %
3.2 %
< 10.0 %
1.7 %
2
CSE: failures
• 10% failure rate / Collis, IJOA ’94
– new technique
– senior & junior anaesthetists
• Albright & Forster, ’99
– 6000 CSEs in a community hospital
– senior anesthesiologists
– < 0.4% failure rate
CSE: Technical failures

Spinal needle too short

Spinal needle tents dura mater

Incorrect epidural needle position
dura
lig.
Flavum
Rawal et al. Reg Anesth. 1997
CSE locking devices
• Locking needle devices
• Reduce
/
eliminate
spinal
needle
movement
Portex CSEcure
• Spinal needle locked within epidural
needle
• Spinal needle immobilisesed during
injection
B-D Durasafe Plus
LABORE EPIDURAL ANALGESIA
CSE VS LEA
 Rapid Onset
 “Walking Epidural”
 PDPH
 Epidural Catheter for Supplemental Analgesia.
 Epidural Catheter for Surgical Anesthesia.
Connelly NR et al. Anesth Analg 2000; 91:374-378
Epidural
100 g fentanyl
20 g sufentanil
Rapid, similar & adequate pain relief
CSE has faster Analgesic
Onset???
Hepner Can J Anaesth 2000 RCT (N=50)
CSE (2.5 mg B + 25 µg F) vs
LEA (10 ml 0.0625% B + 2 µg/ml F)
Time to perform and Parturient satisfaction = Similar
VASP < 30 at 3 min: 26/26 CSE vs. 17/24 LEA (P<.001)
? Clinical Relevance of faster onset as measured in minutes!
Nickells Anaesth 2000 RCT (N=142)
CSE: 2.5 mg B + 25 µg F vs 10 ml 0.125% B + 2 µg/ml F
Time to 0 VASP: 10.0 ± 5.7 vs. 12.1 ± 6.5 min (P = .054)
Does a few minutes delay make a BIG difference?
CSE VS LEA
Rapid Onset
 “Walking Epidural”
 PDPH
Epidural Catheter for Supplemental Analgesia.
Epidural Catheter for Surgical Anesthesia.
LEA in Labor Analgesia
Better ambulation?
 Epidural opioids without local anesthetic
 Epidural opioids with local anesthetic`
“Ambulatory” Labour Epidural Analgesia:
Bupivacaine versus Ropivacaine
Campbell DC,Zwack RM, et al. Anesth Analg (June) 90:13849, 2000
Prospective, Randomized, Double-Blind
40 Nulliparous, Active Labour, < 5 cm Cx Dilatation
“20 ml” 0.08% B + 2 g/ml F (N=20)
“20 ml” 0.08% R + 2 g/ml F (N=20)
“Ambulatory” Labour Epidural Analgesia:
Bupivacaine versus Ropivacaine
Campbell DC, Zwack RM, et al. Anesth Analg (June) 90:1384-9,
2000
100
90
80
70
VAS
Pain
20 ml
0.08% Ropiv or Bupiv
+ 2 g/ml Fent
60
50
40
30
20
10
0
0
2
4
6
0.08% Bupiv + 2 mcg/ml Fent (N=18)
8
10
Time (min)
15
20
0.08% Ropiv + 2 mcg/ml Fent (N=19)
“Ambulatory” Labour Epidural Analgesia:
Bupivacaine versus Ropivacaine
Campbell DC, Zwack RM, et al. Anesth Analg
(June) 90:1384-9, 2000
20 ml 0.08% Ropiv + 2 g/ml Fent
 Effective Labour Analgesia <10 min: (NS)
100% Ambulation at 30 min (P< 0.03)
100% Void Spontaneous (P< 0.01)
 Fewer Forceps (P< 0.05)
CSE VS LEA
 Rapid Onset
 “Walking Epidural”
 PDPH
 Epidural Catheter for Supplemental Analgesia.
 Epidural Catheter for Surgical Anesthesia.
Lower incidence of PDPH in CSE?
 Double Jeopardy-Double Risk (Two
Needles)
 Compared to spinal analgesia?
 Compared to epidural analgesia?
CSE VS LEA
 Rapid Onset
 “Walking Epidural”
 PDPH
 Epidural Catheter for Supplemental Analgesia
Technical Issues
Needle-through-needle technique
Spinal needle
Epidural needle
Needle-through-needle technique
Disadvantage
No separation of spinal and epidural route
Intermittent vs Continuous Administration of Epidural
Ropivacaine With Fentanyl for Analgesia During Labour.
P. D. W. Fettes et al.
(Br J Anaesth, 97:359–364, 2006)
• Evidence is presented that intermittent boluses of
local anesthetic in labor are more effective than
continuous infusions.
CSE OR LEA?
 “Walking Spinal” for 60-120 minutes max.
 Where is the Epidural catheter??
 You want how much for that Spinal Needle?
“Walking Epidural” via Ropivacaine + Fentanyl
Low Concentration/Fractionated = Safe
Effective Labour Analgesia  Effective Surgical Anesthesia
Ideal labour analgesia ?
• Mother
• Fast, effective, continuous analgesia; mobility &
2nd stage pushing.
Ideal labour analgesia ?
• Obstetrician
• No effect on labour outcome.
Ideal labour analgesia ?
• Neonatologist
• No effect on neonatal outcome.
Ideal labour analgesia ?
• Anaesthetist
• All the above + no side effects, complications,
risks.
Fight is on!
Join in!
Dr. Fatma Al Dammas