Epidural Anesthesia

Aka: Epidural Anesthesia, Combination Regional Anesthesia in Labor, Walking Epidural, Neuraxial Anesthesia in Labor

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II. Indications

  1. Contractions regular and strong
  2. Fetal head engaged
  3. Adequate cervical dilatation
    1. Multiparous: Cervix dilated to 4-5 cm
    2. Nulliparous: Cervix dilated to 5-6 cm

III. Contraindications

  1. Coagulopathy
  2. Increased Intracranial Pressure
  3. Hypovolemia

IV. Disadvantages

  1. Indwelling catheter limits mobility
  2. Larger volume of Anesthetic required to fill the epidural space
  3. Onset of pain relief delayed 15 minutes from catheter insertion (contrast with Intrathecal Morphine's instantaneous onset)

V. Technique

  1. Insert indwelling catheter into epidural space
    1. Gauge: 18-20
    2. Insertion Site: L3-4 interspace with Touhy Needle
    3. Elevate head of bed 20-30 degrees
  2. Early active phase
    1. Bupivacaine 0.25% 6-8 ml every 1 to 1.5 hours
    2. Spinal level: T10 to L1
  3. Later first stage to early second stage
    1. Bupivacaine 0.25% 8-12 ml every 1 to 2 hours
    2. Spinal level: T10 to S5

VI. Technique: Combination Regional Anesthesia (Walking Epidural, low-dose epidural protocol)

  1. Uses a combined injection of spinal (intrathecal) and Epidural Anesthesia
    1. Epidural needle enters epidural space
    2. Spinal needle is threaded through epidural needle and then punctures dura and enters subarachnoid space
      1. Spinal Anesthesia (intrathecal Analgesic or Anesthetic) is injected into subarachnoid space
    3. Spinal needle is withdrawn
    4. Epidural catheter is advanced within the epidural space
      1. Epidural catheter is left in place for further Epidural Anesthesia and its needle is withdrawn
  2. Lower dose Anesthetic (bupivicaine or ropivicaine) with or without Fentanyl (Duragesic)
    1. Anesthetic only (without Opioid) in subarachnoid space results in fewer side effects (see below)
    2. However, adding Opioid offers faster Analgesic onset and lower Anesthetic dosing
  3. Benefits
    1. Faster onset of pain relief with decreased rescue Anesthesia
    2. Fewer assisted vaginal deliveries
    3. Allows patients to remain ambulatory despite epidural
    4. Similar pain relief to standard epidural
    5. Shorter Second Stage of Labor
  4. Adverse Effects
    1. Increased maternal Pruritus and Nausea
    2. Nonreassuring Fetal Heart Tones
    3. Adverse effects are increased with Opioid and Anesthetic are used in contrast to Anesthetic alone
  5. Reference
    1. (2001) Lancet 358:19-23 [PubMed]
    2. Hattler (2016) Anesth Analg 123(4): 955-64 [PubMed]
    3. Grangier (2020) Int J Obstet Anesth 41:83-103 [PubMed]
    4. Simmons (2012) Cochrane Database Syst Rev (10): CD003401 [PubMed]

VII. Adverse Effects: General

  1. Risks of maternal Hypotension (occurs in up to one third of patients)
    1. Preadministration of Normal Saline 500 to 1000 cc may prevent Hypotension in Epidural Anesthesia
  2. Systemic injection
    1. Stop if Dizziness or Tinnitus after test dose
  3. Fever
  4. Spinal Headache
  5. Nerve injury
  6. High Neuraxial Block (excessive analgesia) with cardiorespiratory compromise (1 in 4000)
  7. Respiratory arrest (1 in 10,000)
  8. Spinal catheter placement (1 in 15,000)

VIII. Adverse Effects: Labor progress and outcomes

  1. Higher risk of Labor Dystocia if Cervix <5 cm in early studies
    1. Early epidural: 21% Cesarean Section rate
    2. Late epidural: 11% Cesarean Section rate
    3. Lieberman (1995) Perinatal Confer, John's Hopkins
  2. More recent study shows no benefit to epidural delay
    1. Labor slowed only between 4-5 cm (not <4 cm)
    2. No increase in ceserean with early epidural
    3. Vahratian (2004) Am J Obstet Gynecol 191:259-65 [PubMed]
  3. Most recent data shows no increased rate of Assisted Delivery or cesarean delivery regardless of labor stage
    1. Anim-Somuah (2018) Cochrane Database Syst Rev (5): CD000331 [PubMed]
  4. Measures to reduce first-stage of labor time in Epidural Anesthesia
    1. Peanut ball with regular position changes reduces First Stage of Labor time by 87 minutes
    2. Delgado (2022) Obstet Gynaecol 42(5): 726-33 [PubMed]

IX. References

  1. Schrock (2012) Am Fam Physician 85(5): 447-54 [PubMed]
  2. Smith (2021) Am Fam Physician 103(6): 355-64 [PubMed]

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Related Studies

Ontology: Epidural Anesthesia (C0002913)

Definition (NCI) An anesthetic procedure that involves administering pharmaceutical agents into the epidural space of the spinal canal. Frequently administered agents include local anesthetics and analgesics.
Definition (NCI_NCI-GLOSS) An injection of an anesthetic drug into the space between the wall of the spinal canal and the covering of the spinal cord.
Definition (CSP) regional loss of feeling or sensation resulting from injection of an anesthetic into the epidural space of the spinal cord; sensation is lost in the abdominal and genital and pelvic areas; used in childbirth and gynecological surgery.
Concepts Therapeutic or Preventive Procedure (T061)
MSH D000767
SnomedCT 18946005
English Anesthesia, Epidural, Anesthesia, Extradural, Anesthesia, Peridural, Extradural Anesthesia, Peridural Anesthesia, Epidural Anesthesia, Local anaesthet epidural block, LA - LA epidural block, epidural anesthesia (treatment), epidural anesthesia, epidural anaesthesia, peridural anaesthesia, peridural anesthesia, epidural block, Peridural anesthesia, Epidural anesthesia, Epidural anaesthesia, Epidural block, Extradural block, Peridural anaesthesia, LA - Local anaesthetic epidural block, Local anaesthetic epidural block, LA - Local anesthetic epidural block, Local anesthetic epidural block, Epidural anesthesia (procedure), Epidural Block
German epidurale Anaesthesie, Epiduralanaesthesie, Anästhesie, epidurale, Anästhesie, Extradural-, Anästhesie, Peridural-, Epiduralanästhesie
Swedish Epiduralbedövning
Japanese ｺｳﾏｸｶﾞｲﾏｽｲ, 硬膜外麻酔, 硬麻, 硬膜外麻酔法, 脊椎硬膜外麻酔, 脊椎硬膜外麻酔法, 麻酔-硬膜外, 麻酔法-硬膜外
Czech anestézie peridurální, anestézie epidurální, Epidurální anestezie
Finnish Epiduraalianestesia
Italian Anestesia peridurale, Anestesia extradurale, Anestesia epidurale
Russian ANESTEZIIA PERIDURAL'NAIA, ANESTEZIIA EPIDURAL'NAIA, ANESTEZIIA EKSTRADURAL'NAIA, АНЕСТЕЗИЯ ПЕРИДУРАЛЬНАЯ, АНЕСТЕЗИЯ ЭКСТРАДУРАЛЬНАЯ, АНЕСТЕЗИЯ ЭПИДУРАЛЬНАЯ
French Anesthésie épidurale, Péridurale, Anesthésie extradurale, Anesthésie péridurale
Croatian ANESTEZIJA, EPIDURALNA
Polish Znieczulenie zewnątrzoponowe, Znieczulenie nadoponowe
Hungarian Epiduralis anaesthesia
Norwegian Epiduralanestesi, Peridural anestesi, Anestesi, epidural, Ekstradural anestesi
Spanish anestesia epidural (procedimiento), anestesia epidural, anestesia peridural, bloqueo anestésico local epidural, bloqueo extradural, Anestesia epidural, Anestesia Epidural, Anestesia Extradural, Anestesia Peridural
Portuguese Anestesia epidural, Anestesia Epidural, Anestesia Extradural, Anestesia Peridural
Dutch epidurale anesthesie, Anesthesie, epidurale, Epidurale anesthesie
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Combined spinal/epidural local anesthetic block (C0394838)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 231261002
English Combined spinal/epidur LA bloc, Combined spinal/epidural block, Combined spinal/epidural local anaesthetic block, Combined spinal/epidural local anesthetic block, CSE - combined spinal epidural anaesthesia, CSE - combined spinal epidural anesthesia, Combined spinal/epidural local anesthetic block (procedure)
Spanish bloqueo con anestesia local combinada espinal/epidural (procedimiento), bloqueo con anestesia local combinada espinal/epidural
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Pharmacology

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