© Springer International Publishing AG 2017
Linda S. Aglio and Richard D. Urman (eds.)Anesthesiologyhttps://doi.org/10.1007/978-3-319-50141-3_4848. Labor and Delivery
(1)
Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women’s Hospital, 75 Francis St. CWN L1, Boston, MA 02115, USA
Keywords
Labor epiduralCombined spinal epiduralDural puncture epiduralContinuous spinal analgesiaFetal heart monitoringThis morning, a 31-year-old nulliparous woman presents for labor after spontaneous rupture of the membranes. Other than mild asthma treated occasionally with an albuterol inhaler, her pregnancy has been unremarkable. Her last meal was 1 h ago. She requests an epidural.
Medications:
Prenatal vitamins, daily
Albuterol, as needed
Allergies
No known drug allergies
Past Medical History
Mild asthma
Physical exam
Vital signs
Heart rate 86/min, Blood Pressure 98/62 mmHg, Respirations 22/min, Oxygen Saturation 98%
Lungs
Clear to auscultation, no wheezing
Heart
Regular rate and rhythm, no murmurs
Back
No scoliosis
- 1.
What are the indications/contraindications for labor epidural?
The epidural is a very safe and efficient technique for pain control during labor.
Indications:
Patient’s request. Historically, the placement of epidural was advised only after the parturient has reached certain cervical dilation, since it was once believed that the procedure may increase the rate of cesarean delivery. Since this belief has never been proven, an epidural can be placed at any stage of the labor [1].
Established labor, defined as regular contractions, which results in cervical dilation.
Lack of contraindications.
Contraindications:
Patient’s refusal or inability to cooperate.
Coagulation disorders—thrombocytopenia, concurrent use of anticoagulants, DIC, or other causes of coagulopathy—which pose increased risk of epidural hematoma.
Infection—localized, at the site of insertion or untreated systemic infection—which pose risk of introducing the infection to the CNS.
CNS space-occupying lesion associated with increased intracranial pressure—tumor, cyst, or vascular malformation—which pose risk of brain herniation in the case of dural puncture.
Lack of training, experience of the personnel, or inadequate staffing—which prevent the safe placement and monitoring 24/7 of parturients with epidural analgesia.
The epidural placement may be technically challenging in patients with lumbar scoliosis, especially in the presence of spinal instrumentation, high BMI, advanced labor and history of previous difficult placement.
- 2.
What are the advantages/disadvantages of the epidural?
Advantages:
The best method for pain control during labor.
High level of maternal satisfaction.
Very low fetal exposure to medications.
Ability for fast and safe conversion to anesthesia if urgent/emergent instrumental vaginal or cesarean delivery is needed.
Disadvantages:
Risk of complications.
Offered mostly at hospitals that have 24/7 obstetric anesthesia staffing.
Need to maintain IV access and bladder drainage (usually using Foley catheter) throughout labor.
Potential confinement of the parturient to the hospital bed due to concern for motor block.
Recovery period after the delivery for the motor and sensory block to resolve.
- 3.
What are the complications of epidural analgesia?
The complications of the epidural include:
Uneven block, multiple attempts, and failed epidural necessitating replacement. This commonly happens in about 10% of all epidural placements and can be related to technical difficulties (scoliosis, maternal inability to cooperate, inexperienced operator), suboptimal location of the epidural catheter tip (for example, due to migration), and unknown reasons.
Accidental intrathecal or intravascular placement. This puts the patient at risk for high block and total spinal anesthesia (if intrathecal catheter) or intravascular injection of high dose of local anesthetic (if intravascular catheter). In the case of dural puncture, there is a risk for post-dural puncture headache.
Extensive or prolonged block. This usually happens if there is a high concentration and high dose of local anesthetic used.
Neurological injury, epidural abscess, and epidural hematoma. The incidence of these complications is extremely rare, but since any of these can be permanent and devastating, much attention should be paid on proper technique and monitoring for these complications.
- 4.
What are the side effects of epidural analgesia?
Pruritus due to the administration of epidural opioid. The cause of this side effect is largely unknown, but possibly related to central activation of opioid mu-receptors. Usually, this type of pruritus is transient and thus requires no intervention; if necessary it can be treated with opioid antagonists (naloxone), partial agonists–antagonists (nalbuphine), or antihistamines (diphenhydramine).
Nausea and vomiting. The incidence of nausea and vomiting during labor, even in the absence of epidural analgesia, is quite high due to multiple mediators. However, the presence of epidural opioid elevates the risk even higher. Thus, a possible prevention in patients with prior history of nausea and vomiting due to opioids is omission of the opioid from the epidural solution. Alternatively, if it has already developed, this side effect can be treated with antiemetics in the absence of contraindications.Related posts:
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