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Epidural Anesthesia

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Epidural Anesthesia, Combination Regional Anesthesia in Labor, Walking Epidural

  • 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
  • Contraindications
  • 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)
  • 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
  1. Uses a combined injection of spinal (intrathecal) and Epidural Anesthesia
  2. Lower dose anesthetic (bupivicaine or ropivicaine) with Fentanyl (Duragesic)
  3. Allows patients to remain ambulatory despite epidural
  4. Similar pain relief to standard epidural
  5. Lower initial APGAR Scores, but similar outcomes
  6. Small study showed significant benefits
    1. Higher normal Vaginal Delivery rate
    2. Lower instrumented delivery rate
    3. Shorter second stage of labor
  7. Reference
    1. (2001) Lancet 358:19-23 [PubMed]
  • Adverse Effects
  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. Mixed data on labor progress and outcomes
    1. Higher risk of Labor Dystocia if Cervix <5 cm
      1. Early epidural: 21% Cesarean Section rate
      2. Late epidural: 11% Cesarean Section rate
      3. Reference
        1. 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]