Labor Analgesia an Update

7/30/2019 Labor Analgesia an Update

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LABOR ANALGESIA: ANUPDATE

DR. FATMA AL DAMMAS

CONSULTANT

OBSTETRIC ANAESTHESIA AND PAIN

DEPARTMENT OF ANAESTHSIOLOGY

KING KHALID UNIVERSITY HOSPITAL

RIYADH.


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LABOR ANALGESIA: AN

UPDATEIS THERE AN ADVANTAGE OF

CSE OVER EPIDURAL?

DR. FATMA AL DAMMAS

CONSULTANT

OBSTETRIC ANAESTHESIA AND PAIN

DEPARTMENT OF ANAESTHSIOLOGY

KING KHALID UNIVERSITY HOSPITAL

RIYADH.


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CONTENTS

Introduction

CSE

Epidural analgesia

Review articles


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Stages of Labour


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Pain pathways during labor


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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 andside effects are well documented.


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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.


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IDEALLabour Analgesia

Safe (mother, fetus) Composure, Control (Pain, Pain Relief)

Ease of Administration

Rapid, Profound, Consistent Analgesia(Stage I & II)

No Effect: Ambulation

Maternal Expulsive EffortsProgress of Labour

Facilitate Surgical Anesthesia avoiding GA


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CSE LEA


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CSE ADVANTAGES Rapid Onset IT Component

Better Blocks

IT Medications Devoid of Motor BlockadeWalkingEpidural

Atraumatic Spinal Needles (fewer PDPH?).

Epidural Catheter for Supplemental Analgesia.

Epidural Catheter for Surgical Anesthesia.


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CSE ADVANTAGESRapid Onset IT Component

Better Blocks






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Rapid Onset of Analgesia

Most dramatic feature; analgesia is often nearly

complete before the epidural cath. is taped upand the tray discarded


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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


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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 CSEgroup, only 17/24 in the epidural group


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Does a few minutes advantage in

analgesic onset matter?


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Better Blocks






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Better Blocks

Quality of analgesia is improved by CSE

Norris retrospectively compared epid. and CSE

techniques in 1661 women who received eithertechnique 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


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CSE cannot be obtained using the needle-through-

needle 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.

Better Blocks


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Better Blocks






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Less Motor Block

CSE associated with less total LA use for a given degreeof analgesia

In a randomized trial, Collis found 12/98 patients in theCSE group, compared to 32/99 in the epid group had legweakness 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.


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Protocol for Ambulation

A patient must remain at bed rest for at least 30 minutesfollowing initiation of CSE.

Prior to ambulation, approval must be obtained from the

labor nurse, obstetrician, and anesthesiologist. FHRtracing must be within normal limits prior to ambulation.

Ambulation is allowed only after the patient has beenexamined by the anesthesiologist to rule out motor block.

A BP measurement taken immediately prior toambulation while the patient is upright.


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Protocol for Ambulation

Ambulating parturients must be supported on one sideby a companion and by an iv pole (with wheels) forsupport on their other side.

If a parturient does not wish to ambulate but wants toget out of bed, (or for patients who need to havecontinuous FHR monitoring), they may be assisted outof bed into the rocking chair adjacent to the bed.


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First steps to

painlessMotherhood!


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Less Motor Block

Adding opioids < MB Walking epidurals: < MB meant better

outcomes

No evidence of improved laborpattern/outcome with ambulation !!!.

Women dont walk even if they can.

Monitoring problems.

Techniques that allow walking may bebetter whether or not patientambulates.


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Davies: Anesthesiology

2002

Updated Computerised dynamicposturography

Assessing relative contributingsomatosensory, visual, vestibular inputto maintain accurate balance

Walk / walk & turn test

Step up & standing up from sitting

After labour CSE

Pregnant control


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Intrathecal Bupivacaine and Sufentanil for Ambulatory Labor Analgesia:

Effect of Dose Reductions

Schultz R, Campbell DC, et al. Anesthlogy (SOAP suppl) A18, 1998

0

10

20

30

40

50

60

70

80

90

100

0 5 10 15 30 45 60 75 90 105 120

S 10 + B 2.5

S 5 + B 1.25

VASPAIN

* P < 0.05

* **

*

*

Time (min)


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Does a Walking epidurals meantbetter in analgesic outcomes?


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Better Blocks

IT Medications Devoid of Motor Blockade

WalkingEpidural





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CSE ADVANTAGESPDPH

Rate ~ 1%

CSE technique might actually decrease the

incidence of dural puncture with the epid needleby 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.


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CSE ADVANTAGES

The use of small bore atraumatic spinal needles willreduce the incidence of PDPH in patients receiving CSE .

Possible explanation for this finding is that, the spinalneedle may be used for verification of correct placement ofthe epidural needle when there is inconclusive loss ofresistance

David J. Birnbach MD ;Advances in labour analgesia . CAN JANESTH 2004 51: 6


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PDPH has advantage over analgesia ?


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CSE ADVANTAGESRapid Onset IT Component

IT Medications Devoid of Motor Blockade Walking

Epidural





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Better Patient Satisfaction

An Updated Report by the American Society of

Anesthesiologists Task Force on Obstetric Anesthesia

Anesthesiology 2007; 106:84363

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


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Better in Difficult Backs

An Updated Report by the American Society of

Anesthesiologists Task Force on Obstetric Anesthesia

Anesthesiology 2007; 106:84363

CSE has been associated with improved chances of

adequate analgesia in parturients with scoliosis or other

causes of a difficult back.


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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


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Progress of Labor

Tow large randomized trials have confirmed an increase in

the spontaneous vaginal delivery rate with CSE vs.

conventional epid analgesia.


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Progress of Labor

The pain relief leads to a decrease in the output of thesympathetic 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 BritishJournal of Anaesthesia July 18, 2006 97 (3): 35964


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A retrospective analysis involving near 20,000 patientsfound incidences of overall failure, IV epid cath, wet tap,inadequate epid analgesia and cath replacement wereall lower in patients receiving CSE.

Sacral analgesia is difficult to obtain with conventionalepidural, CSE is good at providing it.

CSE is an obvious choice in advanced labor.

Other advantage


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Do a few advantages in CSE analgesiamatter?


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CSEComplications Fetal bradycardia/FHR changes

Pruritus

Infection

Neurotrauma

Other side effects


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Fetal

HeartRate

CS


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Post-CSE NRFHR:

FETAL BRADYCARDIA

1993 CohenAnesth Analg 15% (11/73)

1994 ClarkAnesthlogy 30% (9/30)

1997 Campbell DCAnesthlogy 15% (6/39)1998 GamblingAnesthlogy 18% (72/400)

1999 PalmerAnesth Analg 12% (12/100) *

2000 WongAnesthlogy 17% (28/67)

2001 Van de Velde Reg An Pain Man 11% (40/351) *

* 50% greater than Epidural


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How does labour analgesia cause fetal

bradycardia?


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FETAL BRADYCARDIA

1. The pain relief leads to a decrease in the output of the

sympathetic nervous system. There is a significantdecrease in the level of circulating epinephrine after theinduction 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 willbe a subsequent fetal bradycardia.

Edward T. Riley MDCAN J ANESTH 2003 / 50: 6 / pp R1R3


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FETAL BRADYCARDIA

1. Pain relief leads to a decrease in blood pressure.

2. The decrease in blood pressure, norepinephrinelevels increase.

3. This will lead to uterine artery constriction.

4. Uterine artery vasoconstriction will decrease placentalblood flow.

5. If placental blood flow is decreased significantly therewill be a subsequent fetal bradycardia.

Edward T. Riley MDCAN J ANESTH 2003 / 50: 6 / pp R1R3


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Norepinephrine

- effects

uterine tonus uterine

contractions

Epinephrine- effectsuterine tonus

uterine contractions

Rapid onset pain relief may causetemporary norepinephrine predominance

FETAL BRADYCARDIA


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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; 88:577-581Norris MC et al. Anesthesiology 2001; 95:913-920

FETAL BRADYCARDIA


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Pruritus

Infection

Neurotrauma

Other side effects


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Norris MC, et al. Anesth Analg 79:529-37, 1994Complications of Labor Analgesia: Epidural versus

Combined Spinal Epidural Techniques

LEA (n=388) CSE (n=536)

Pruritus 1.3 % 41.3 %


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Pruritus

Infection

Neurotrauma

Other side effects


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Infection

There are least 8 case reports of spinal meningitisrelated 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.


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Pruritus

Infection

Neurotrauma

Other side effects


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Neurotrauma

Cord trauma has been reported with the CSE technique inat least in 5 cases.

In a report of 7 cases with damage to the conus

medullaris following spinal anesthesia by Reynolds ofSaint Thomas Hospital in London, 4 were patients whohad 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 atL2-3.


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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 L3-

L4, in 85% of the cases the space was 1 to as many as 4

segments higher.


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CSE Complications

Fetal bradycardia/FHR changes

Pruritus

Infection

Neurotrauma

Other side effects


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Complications of Labor Analgesia: Epidural versus

Combined Spinal Epidural Techniques Norris MC, et al.

Anesth Analg 79:529-37, 1994

LEA (n=388) CSE (n=536)

Nausea 1.0 % 2.4 %Vomiting 1.0 % 3.2 %

Hypotension < 10.0 % < 10.0 %

Dural Puncture 4.2 % 1.7 %Blood Patch 4 2


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CSE: failures

10% failure rate / Collis, IJOA 94

new technique

senior & junior anaesthetistsAlbright & Forster, 99

6000 CSEs in a community hospital

senior anesthesiologists < 0.4% failure rate


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Rawal et al. Reg An esth. 1997

dura

lig.

Flavum

CSE: Technical failures

Spinal needle too short

Spinal needle tents dura mater

Incorrect epidural needle position


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CSE locking devices

Locking needle devices

Reduce / eliminate spinal needle

movement

Spinal needle locked within epidural

needle

Spinal needle immobilisesed during

injection

B-D Durasafe Plus

Portex CSEcure


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LABORE EPIDURAL ANALGESIA


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CSE VS LEA

Rapid Onset

WalkingEpidural

PDPH




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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


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CSE hasfaster Analgesic

Onset???

HepnerCan J Anaesth 2000 RCT (N=50)

CSE (2.5 mg B + 25 g F) vs

LEA (10 ml 0.0625% B + 2 g/ml F)

Time to perform and Parturient satisfaction = SimilarVASP < 30 at 3 min: 26/26 CSE vs. 17/24 LEA (P


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CSE VS LEA

Rapid Onset

WalkingEpidural

PDPH




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Epidural opioids without local anesthetic

LEA in Labor Analgesia

Better ambulation?

Epidural opioids with local anesthetic`


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AmbulatoryLabour Epidural Analgesia:

Bupivacaine versus Ropivacaine

Campbell DC,Zwack RM, et al. Anesth Analg (June) 90:1384-

9, 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)



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Campbell DC, Zwack RM, et al. Anesth Analg (June) 90:1384-9,

2000

0

1020

30

40

50

60

70

80

90

100

0 2 4 6 8 10 15 20

0.08% Bupiv + 2 mcg/ml Fent (N=18) 0.08% Ropiv + 2 mcg/ml Fent (N=19)

VAS

Pain

Time (min)

20 ml0.08% Ropivor Bupiv

+ 2 g/ml Fent



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y p g


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


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CSE VS LEA

Rapid Onset

WalkingEpidural

PDPH




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Double Jeopardy-Double Risk (TwoNeedles)

Compared to spinal analgesia?

Compared to epidural analgesia?

Lower incidence of PDPH in CSE?


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CSE VS LEA

Rapid Onset

WalkingEpidural

PDPH

Epidural Catheter for Supplemental Analgesia

Technical Issues


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Epidural needle

Spinal needle

Needle-through-needle technique


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Needle-through-needle technique

Disadvantage

No separation of spinal and epidural route

Intermittent vs Continuous Administration of Epidural


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P. D. W. Fettes et al.

(Br J Anaesth, 97:359364, 2006)

Evidence is presented that intermittent boluses oflocal anesthetic in labor are more effective than

continuous infusions.

Intermittent vs Continuous Administration of Epidural

Ropivacaine With Fentanyl for Analgesia During Labour.

CSE OR LEA?


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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


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Ideal labour analgesia ?

Mother

Fast, effective, continuous analgesia; mobility &

2nd stage pushing.


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Obstetrician

No effect on labour outcome.


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Neonatologist

No effect on neonatal outcome.


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Anaesthetist

All the above + no side effects, complications,risks.

Fight is on!


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Fight is on!

Join in!


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Dr. Fatma Al Dammas


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Labor Analgesia an Update