Epidural Analgesia

Epidural labor analgesia was first introduced in the 1940s, when a single dose of local anesthetic was administered into the caudal epidural space. Epidural analgesia is now provided via a lumbar epidural catheter. It is the analgesic technique used for the majority of women in the United States who request analgesia in labor.

The technique for epidural analgesia virtually always involved the insertion of an epidural catheter into the epidural space. This space is accessed by a midline or paramedian approach and identified by "loss of resistance" to air or saline. When the needle tip is in the ligamentum flavum, there is resistance to the injection; this resistance is lost when the epidural space is entered. Once the space is identified, the epidural catheter is inserted through the needle, leaving 2-4 cm within the space. The needle is removed and the catheter is secured to the mother's back (Fig. 22.2).

Supraspinous ligament

Vertebral spine

Vertebral spine

Subarachnoid (spinal) space

Vertebral body mr

Spinal cord

Ligamentum flavum'

Epidural space

Figure 22.2 Anatomy of spinal and epidural anesthesia.

For the past 20 years, anesthesiologists have used a combination of opioid and local anesthetic for labor analgesia. This combination allows for excellent pain relief with minimal or no motor block. We see no difference in the labor outcomes between patients receiving epidural labor analgesia with these solutions and those receiving other analgesic techniques (Wong et al. 2005).

Epidural "mixtures" are listed in Table 22.3 and can be administered as intermittent doses by continuous infusion or using patient-controlled epidural analgesia.

Side effects ofepidural analgesia are few. Epidural local anesthetics can cause sympathetic blockade and hypotension. Administration of intravenous fluids, pressors, or a combination

Tables 22.3 Epidural labor analgesia.

Loading dose

Bupivacaine 0.125% 10 ml with hydromorphone 100 |g or fentanyl 50 |g or sufentanil 10 |g Ropivicaine 0.75% 10 ml with hydromorphone 100 |g or fentanyl 15 |g or sufentanil 10 |g Infusion

Bupivacaine 0.0625-0.125% or ropivacaine 0.075-0.125%

With hydromorphone 3 |g/ml orfentanyl 2 |g/ml or sufentanil 2 |g/ml thereof can treat the side effects. The low-dose local anesthetic (LA) opioid combinations used currently cause minimal hemodynamic disturbance. Since concentrated LA solutions may cause motor blockade, it can be avoided or minimized by using the lowest concentration, compatible with adequate analgesics. Epidural opioids may cause nausea, vomiting, and/or pruritis (itching). These side effects be treated with antiemetics and/or low-dose nalbuphine. Other complications of the epidural technique include a failed or inadequate block, dural puncture, intravascular injection, infection, or neurological complication. Fetal complications may include a transient change in the FHR pattern. In some cases, epidural analgesia may improve placental blood flow (i.e., in patients with pre-eclampsia).

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