Spinal Analgesia

The use of "single shot" spinal analgesia alone and not as part of a CSE technique is most useful in the late stages of labor when delivery is imminent or to provide rapid analgesia for a mother who has "lost control," thus allowing her to "regroup" and cooperate for epidu-ral catheter placement. The main consideration for single shot spinal analgesia is the limited duration of analgesia (60-90 min; Table 22.4) and the risk of post-dural puncture headache. The headache risk can be reduced by using a small gauge (24-25 g) pencil point needle (Sprotte®; B. Braun Medical Inc., Bethlehem, PA) rather than those with cutting tips. The incidence of headache should be <2% and, if it occurs, should be mild.

Table 22.4 Spinal opioids for labor.

Opioid

Dose

Fentanyl

1G-25 |ig in 1 ml normal saline

Sufentanil

2-5 |ig in 1 ml normal saline

Bupivacaine, G.5-1 mg may be added to the solution.

Bupivacaine, G.5-1 mg may be added to the solution.

A "saddle block" or a low spinal anesthetic with a local anesthetic may be used to provide anesthesia in the perineal area (hence "saddle block") for stages 2 and 3 of labor, especially when assisted vaginal delivery is performed (forceps/vacuum). Most commonly used is 5-7 mg of hyperbaric bupivacaine with 10-25 |xg of fentanyl administration in the sitting position, with the patient then placed immediately into the lithotomy position with the head of the bed approximately 45° upright. This helps ensure a "saddle block" distribution of anesthesia.

A continuous spinal catheter technique may be considered in some cases. This is achieved using a standard epidural kit. This technique may be used when an inadvertent dural puncture occurs with the epidural needle. More commonly it is used in patients in whom one may need a rapid onset of surgical anesthesia for operative delivery when a general anesthetic is ill advised (e.g., a morbidly obese patient or a patient with a history of malignant hyperthermia).

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