labor analgesia: an update dr. fatma al dammas consultant obstetric anaesthesia and pain department...
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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 OFCSE OVER EPIDURAL?
DR. FATMA AL DAMMAS CONSULTANT OBSTETRIC ANAESTHESIA AND PAIN
DEPARTMENT OF ANAESTHSIOLOGY
KING KHALID UNIVERSITY HOSPITAL
RIYADH.
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)
FROM THE HOLY QURAN
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 AnalgesiaIDEAL 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 EffortsProgress of Labour
Facilitate Surgical Anesthesia avoiding GA
CSECSE LEALEA
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
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
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
• Updated Computerised dynamic posturography
• Assessing relative contributing somatosensory, visual, vestibular input to maintain accurate balance
• Walk / walk & turn test
• Step up & standing up from sitting
After labour CSE
Pregnant control
Intrathecal Bupivacaine and Sufentanil for Ambulatory Labor Analgesia: Effect of Dose Reductions
Schultz R, Campbell DC, et al. Anesth’logy (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)
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 of Anesthesiologists Task Force on Obstetric Anesthesia
Anesthesiology 2007; 106:843–63
• 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
• 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.
Other advantage
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 15% (11/73)1994 Clark Anesth’logy 30% (9/30)1997 Campbell DC Anesth’logy 15% (6/39)1998 Gambling Anesth’logy 18% (72/400) 1999 Palmer Anesth Analg 12% (12/100) *2000 Wong Anesth’logy 17% (28/67)2001 Van de Velde Reg An Pain Man 11% (40/351) *
* 50% greater than Epidural
How does labour analgesia cause fetal bradycardia?
FETAL BRADYCARDIA1. 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
Norepinephrine- effects
uterine tonus uterine
contractions
Epinephrine- effects
uterine tonus uterine contractions
Rapid onset pain relief may causetemporary norepinephrine predominance
FETAL BRADYCARDIA
Several studies found no increased incidenceof 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
FETAL BRADYCARDIA
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
Norris MC, et al. Anesth Analg 79:529-37, 1994 Complications of Labor Analgesia: Epidural versus Combined Spinal Epidural Techniques
LEA (n=388) CSE (n=536)
Pruritus 1.3 % 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 L3-L4, 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
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
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
Rawal Rawal et al. Reg Anesth. et al. Reg Anesth. 19971997
duradura
lig.lig.FlavumFlavum
CSE: Technical failures
Spinal needle too shortSpinal needle too short
Spinal needle tents dura materSpinal needle tents dura mater
Incorrect epidural needle positionIncorrect epidural needle position
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
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.
Epidural opioids without local anesthetic
LEA in Labor Analgesia
Better ambulation?
Epidural opioids with local anesthetic`
“Ambulatory” Labour Epidural Analgesia: Bupivacaine versus Ropivacaine Campbell DC,Zwack RM, et al. Anesth Analg (June) 90:1384-9, 2000
Prospective, Randomized, Double-Blind40 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
0
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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)
VASVASPainPain
Time (min)Time (min)
20 ml0.08% Ropiv or Bupiv
+ 2 g/ml Fent
“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.
Double Jeopardy-Double Risk (Two Needles)
Compared to spinal analgesia? Compared to epidural analgesia?
Lower incidence of PDPH in CSE?
CSE VS LEA
Rapid Onset
“Walking Epidural”
PDPH
Epidural Catheter for Supplemental Analgesia
Technical Issues
Epidural needle
Spinal needle
Needle-through-needle technique
Needle-through-needle technique
Disadvantage
No separation of spinal and epidural route
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.
Intermittent vs Continuous Administration of Epidural Ropivacaine With Fentanyl for Analgesia During Labour.
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 = SafeEffective 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