LABOR ANALGESIA: AN UPDATE DR. FATMA AL DAMMAS CONSULTANT OBSTETRIC ANAESTHESIA AND PAIN DEPARTMENT OF ANAESTHSIOLOGY KING KHALID UNIVERSITY HOSPITAL RIYADH.

LABOR ANALGESIA: AN UPDATE IS THERE AN ADVANTAGE OF CSE OVER EPIDURAL? DR. FATMA AL DAMMAS CONSULTANT OBSTETRIC ANAESTHESIA AND PAIN DEPARTMENT OF ANAESTHSIOLOGY KING KHALID UNIVERSITY HOSPITAL RIYADH.

IN THE NAME OF ALLAH THE MOST BENEFICIENT THE MOST MERCIFUL “AND THE PAINS OF CHILDBIRTH DROVE HER TO THE TRUNK OF A DATE PALM. SHE SAID “ WOULD THAT I HAD DIED BEFORE THIS, AND HAD BEEN FORGOTTEN AND OUT OF SIGHT”. SURAH 19: 23 (SURAH MARYAM) FROM THE HOLY QURAN

CONTENTS Introduction CSE Epidural analgesia Review articles

Stages of Labour

Pain pathways during labor

INTRODUCTION There are many different techniques, both regional and non-regional to provide labour analgesia. Non-regional techniques are the most frequently employed methods for labour analgesia. Meperidine (pethidine) is the most frequently used opioid for labour analgesia. Its limited efficacy and side effects are well documented.

INTRODUCTION Inhalation of nitrous oxide relieves labour pain to a significant degree. Epidural analgesia, CSA, PCEA,when compared with other methods, provides superior analgesia for labour.

IDEAL Labour Analgesia F Safe (mother, fetus) F Composure, Control (Pain, Pain Relief) F Ease of Administration F Rapid, Profound, Consistent Analgesia (Stage I & II) F No Effect:Ambulation Maternal Expulsive Efforts Progress of Labour FFacilitate Surgical Anesthesia avoiding GA

CSE LEA

CSE ADVANTAGES ½ Rapid Onset IT Component ½ Better Blocks ½ IT Medications Devoid of Motor Blockade “Walking Epidural” ½ Atraumatic Spinal Needles (fewer PDPH?). ½ Epidural Catheter for Supplemental Analgesia. ½ Epidural Catheter for Surgical Anesthesia.

CSE ADVANTAGES ½ Rapid Onset IT Component ½ Better Blocks ½ IT Medications Devoid of Motor Blockade “Walking Epidural” ½ Atraumatic Spinal Needles (fewer PDPH?). ½ Epidural Catheter for Supplemental Analgesia. ½ Epidural Catheter for Surgical Anesthesia.

Rapid Onset of Analgesia Most dramatic feature; analgesia is often nearly complete before the epidural cath. is taped up and the tray discarded

Rapid Onset of Analgesia Van de Velde randomized 110 parturients to epid. BUP 0.125% w sufentanil and epinephrine or IT sufentanil. The time to effective analgesia was significantly shorter in the CSE group. Van de Velde M: CSA in labor. Anesthesiology 2000 ;92:869-70

Rapid Onset of Analgesia Nickells randomized women to epid. or SA BUP and fentanyl. The time to first painless contraction was shorter in the CSE group ( 10 ± 5.7 vs ± 6.5min) Hepner randomized women to receive 10ml of % BUP + fentanyl 2mcg/ml + epinephrine + bicarbonate epidurally or 25mcg fentanyl and 2.5mg BUP IT –26/26 patients had a VAS < 3 within 5min in CSE group, only 17/24 in the epidural group

Does a few minutes advantage in analgesic onset matter?

CSE ADVANTAGES ½ Rapid Onset IT Component ½ Better Blocks ½ IT Medications Devoid of Motor Blockade “Walking Epidural” ½ Atraumatic Spinal Needles (fewer PDPH?). ½ Epidural Catheter for Supplemental Analgesia. ½ Epidural Catheter for Surgical Anesthesia.

Better Blocks Quality of analgesia is improved by CSE Norris retrospectively compared epid. and CSE techniques in 1661 women who received either technique and found a lower incidence of failed blocks and a greater incidence of bilateral symmetrical analgesia w CSE. Norris MC.Anesth Analg 1995;79:529-37

CSE cannot be obtained using the needle-through- needle technique unless the epid needle is positioned near the mid line of the actual epid space. There may be passage of LA from the epidural space into the IT space via the dural hole. There may be synergism between epid and spinal blocks, such that one enhances the other. Better Blocks

CSE ADVANTAGES ½ Rapid Onset IT Component ½ Better Blocks ½ IT Medications Devoid of Motor Blockade “Walking Epidural” ½ Atraumatic Spinal Needles (fewer PDPH?). ½ Epidural Catheter for Supplemental Analgesia. ½ Epidural Catheter for Surgical Anesthesia.

Less Motor Block CSE associated with less total LA use for a given degree of analgesia In a randomized trial, Collis found 12/98 patients in the CSE group, compared to 32/99 in the epid group had leg weakness at 20min. Requirements for anesthesiologist intervention are lower w CSE regardless of technique. Collis RE. Davies DWL. Aveling W. Randomised comparison of CSE and standard epidural in labour Lancet 1995,

Protocol for Ambulation A patient must remain at bed rest for at least 30 minutes following initiation of CSE. Prior to ambulation, approval must be obtained from the labor nurse, obstetrician, and anesthesiologist. FHR tracing must be within normal limits prior to ambulation. Ambulation is allowed only after the patient has been examined by the anesthesiologist to rule out motor block. A BP measurement taken immediately prior to ambulation while the patient is upright.

Protocol for Ambulation Ambulating parturients must be supported on one side by a companion and by an iv pole (with wheels) for support on their other side. If a parturient does not wish to ambulate but wants to get out of bed, (or for patients who need to have continuous FHR monitoring), they may be assisted out of bed into the rocking chair adjacent to the bed.

First steps to painless Motherhood!

Less Motor Block Adding opioids < MB “Walking” epidurals: < MB meant better outcomes –No evidence of improved labor pattern/outcome with ambulation !!!. –Women don’t walk even if they can. –Monitoring problems. –Techniques that allow “walking” may be “better” whether or not patient ambulates.

Davies: Anesthesiology 2002 Updated Computerised dynamic posturography Assessing relative contributing somatosensory, visual, vestibular input to maintain accurate balance Walk / walk & turn test Step up & standing up from sitting After labour CSE Pregnant control

Intrathecal Bupivacaine and Sufentanil for Ambulatory Labor Analgesia: Effect of Dose Reductions Schultz R, Campbell DC, et al. Anesth’logy (SOAP suppl) A18, 1998 VAS PAIN * P < 0.05 * * * * * Time (min)

Does a Walking” epidurals meant better in analgesic outcomes?

CSE ADVANTAGES ½ Rapid Onset IT Component ½ Better Blocks ½ IT Medications Devoid of Motor Blockade “Walking Epidural” ½ Atraumatic Spinal Needles (fewer PDPH?). ½ Epidural Catheter for Supplemental Analgesia. ½ Epidural Catheter for Surgical Anesthesia.

CSE ADVANTAGES PDPH –Rate ~ 1% –CSE technique might actually decrease the incidence of dural puncture with the epid needle by allowing the anesthesiologist to confirm an equivocal loss of resistance by passage of a pencil point spinal needle rather than advancing the large bore epid needle further.

CSE ADVANTAGES The use of small bore “atraumatic” spinal needles will reduce the incidence of PDPH in patients receiving CSE. Possible explanation for this finding is that, the spinal needle may be used for verification of correct placement of the epidural needle when there is inconclusive loss of resistance David J. Birnbach MD ;Advances in labour analgesia. CAN J ANESTH : 6

↓ PDPH has advantage over analgesia ?

CSE ADVANTAGES ½Rapid Onset IT Component ½IT Medications Devoid of Motor Blockade “Walking Epidural” ½Atraumatic Spinal Needles (fewer PDPH?). ½Epidural Catheter for Supplemental Analgesia. ½Epidural Catheter for Surgical Anesthesia.

Better Patient Satisfaction An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia Anesthesiology 2007; 106:843–63 Several studies have found better patient satisfaction scores with CSE vs. conventional epid. Others have found no difference, but none have found better satisfaction with conventional epid analgesia

Better in Difficult Backs An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia Anesthesiology 2007; 106:843–63 CSE has been associated with improved chances of adequate analgesia in parturients with scoliosis or other causes of a difficult back.

Progress of Labor Studies have compared obstetric outcomes associated with CSE and epidural labor analgesia. Tsen et al. reported faster initial cervical dilation and shorter time from induction of analgesia to full cervical dilation among women receiving CSE analgesia vs epidural analgesia. Tsen L.C,Thue BDatta S: Anesthesiology 2001;91;920-5

Progress of Labor Tow large randomized trials have confirmed an increase in the spontaneous vaginal delivery rate with CSE vs. conventional epid analgesia.

Progress of Labor The pain relief leads to a decrease in the output of the sympathetic nervous system. There is a significant decrease in the level of circulating epinephrine after the induction of labour analgesia. Epinephrine is a tocolytic. A decrease in epinephrine will cause an increase in uterine tone P. D. W. Fettes, C. S. Moore1 analgesia during labour British Journal of Anaesthesia July 18, (3): 359–64

A retrospective analysis involving near 20,000 patients found incidences of overall failure, IV epid cath, wet tap, inadequate epid analgesia and cath replacement were all lower in patients receiving CSE. Sacral analgesia is difficult to obtain with conventional epidural, CSE is good at providing it. CSE is an obvious choice in advanced labor. Other advantage

Do a few advantages in CSE analgesia matter?

CSE Complications Fetal bradycardia/FHR changes Pruritus Infection Neurotrauma Other side effects

Fetal Heart Rate

Post-CSE NRFHR: FETAL BRADYCARDIA Ñ1993 Cohen Anesth Analg 15% (11/73) Ñ1994 Clark Anesth’logy 30% (9/30) ª1997 Campbell DC Anesth’logy 15% (6/39) Ñ1998 Gambling Anesth’logy 18% (72/400) Ñ1999 Palmer Anesth Analg 12% (12/100) * Ñ2000 Wong Anesth’logy 17% (28/67) Ñ2001 Van de Velde Reg An Pain Man 11% (40/351) * * 50% greater than Epidural

How does labour analgesia cause fetal bradycardia?

FETAL BRADYCARDIA 1. The pain relief leads to a decrease in the output of the sympathetic nervous system. There is a significant decrease in the level of circulating epinephrine after the induction of labour analgesia. 2. Epinephrine is a tocolytic. A decrease in epinephrine will cause an increase in uterine tone. 3. Increased uterine tone will decrease placental blood flow. 4. If placental blood flow is decreased significantly there will be a subsequent fetal bradycardia. Edward T. Riley MDCAN J ANESTH 2003 / 50: 6 / pp R1–R3

FETAL BRADYCARDIA 1. Pain relief leads to a decrease in blood pressure. 2. The decrease in blood pressure, norepinephrine levels increase. 3. This will lead to uterine artery constriction. 4. Uterine artery vasoconstriction will decrease placental blood flow. 5. If placental blood flow is decreased significantly there will be a subsequent fetal bradycardia. Edward T. Riley MDCAN J ANESTH 2003 / 50: 6 / pp R1–R3

Norepinephrine  - effects uterine tonus  uterine contractions  Epinephrine  - effects uterine tonus  uterine contractions  Rapid onset pain relief may cause temporary norepinephrine predominance FETAL BRADYCARDIA

Several studies found no increased incidence of fetal heart rate abnormalities or increased Caesarean section rate ~ CSE* * Nielsen PE et al. Anesth Analg 1996; 83: Albright GA et al. Reg Anesth 1997; 22: Eberle RL et al. Am J Obstet Gynecol 1998; 179: Palmer CM et al. Anesth Analg 1999; 88: Norris MC et al. Anesthesiology 2001; 95: FETAL BRADYCARDIA

CSE Complications Fetal bradycardia/FHR changes Pruritus Infection Neurotrauma Other side effects

Norris MC, et al. Anesth Analg 79:529-37, 1994 Complications of Labor Analgesia: Epidural versus Combined Spinal Epidural Techniques LEA (n=388) CSE (n=536) Pruritus 1.3 % 41.3 %

CSE Complications Fetal bradycardia/FHR changes Pruritus Infection Neurotrauma Other side effects

Infection There are least 8 case reports of spinal meningitis related to a CSE. Too many instrumentations- Too many cooks spoil a broth? There is also a case report of epid abscess after a CSE for labor. Conversely spinal anesthesia for elective CS does not carry these risks.

CSE Complications Fetal bradycardia/FHR changes Pruritus Infection Neurotrauma Other side effects

Neurotrauma Cord trauma has been reported with the CSE technique in at least in 5 cases. In a report of 7 cases with damage to the conus medullaris following spinal anesthesia by Reynolds of Saint Thomas Hospital in London, 4 were patients who had received a CSE and 3 after a single shot spinal. In all cases, an atraumatic needle was used, 25 or 27 gauge Whitacre and the anesthesiologist believed to be at L2-3.

Van Gessel et al. demonstrated that 59% of dural punctures were performed 1 or 2 spaces higher than assumed. Broadbent et al. demonstrated in a group of experienced anesthesiologists that when they believed they were at L3- L4, in 85% of the cases the space was 1 to as many as 4 segments higher.

CSE Complications Fetal bradycardia/FHR changes Pruritus Infection Neurotrauma Other side effects

Complications of Labor Analgesia: Epidural versus Combined Spinal Epidural Techniques Norris MC, et al. Anesth Analg 79:529-37, 1994 LEA (n=388) CSE (n=536) Nausea 1.0 % 2.4 % Vomiting 1.0 % 3.2 % Hypotension < 10.0 % < 10.0 % Dural Puncture 4.2 % 1.7 % Blood Patch 4 2

CSE: failures 10% failure rate / Collis, IJOA ’94 –new technique –senior & junior anaesthetists Albright & Forster, ’99 – 6000 CSEs in a community hospital –senior anesthesiologists –< 0.4% failure rate

Rawal et al. Reg Anesth dura lig.Flavum CSE: Technical failures  Spinal needle too short  Spinal needle tents dura mater  Incorrect epidural needle position

CSE locking devices Locking needle devices Reduce / eliminate spinal needle movement Spinal needle locked within epidural needle Spinal needle immobilisesed during injection B-D Durasafe Plus Portex CSEcure

LABORE EPIDURAL ANALGESIA

CSE VS LEA ½ Rapid Onset ½ “Walking Epidural” ½ PDPH ½ Epidural Catheter for Supplemental Analgesia. ½ Epidural Catheter for Surgical Anesthesia.

Connelly NR et al. Anesth Analg 2000; 91: Epidural 100  g fentanyl 20  g sufentanil Rapid, similar & adequate pain relief

CSE has faster Analgesic Onset??? Hepner Can J Anaesth 2000 RCT (N=50) CSE (2.5 mg B + 25 µg F) vs LEA (10 ml % B + 2 µg/ml F) Time to perform and Parturient satisfaction = Similar VASP < 30 at 3 min: 26/26 CSE vs. 17/24 LEA (P<.001) ? Clinical Relevance of faster onset as measured in minutes! Nickells Anaesth 2000 RCT (N=142) CSE: 2.5 mg B + 25 µg F vs 10 ml 0.125% B + 2 µg/ml F Time to 0 VASP: 10.0 ± 5.7 vs ± 6.5 min (P =.054) Does a few minutes delay make a BIG difference?

CSE VS LEA ½Rapid Onset ½ “Walking Epidural” ½ PDPH ½Epidural Catheter for Supplemental Analgesia. ½Epidural Catheter for Surgical Anesthesia.

 Epidural opioids without local anesthetic LEA in Labor Analgesia Better ambulation?  Epidural opioids with local anesthetic`

“Ambulatory” Labour Epidural Analgesia: Bupivacaine versus Ropivacaine Campbell DC,Zwack RM, et al. Anesth Analg (June) 90: , 2000 ªProspective, Randomized, Double-Blind ª40 Nulliparous, Active Labour, < 5 cm Cx Dilatation “20 ml” 0.08% B + 2  g/ml F (N=20) “20 ml” 0.08% R + 2  g/ml F (N=20)

“Ambulatory” Labour Epidural Analgesia: Bupivacaine versus Ropivacaine Campbell DC, Zwack RM, et al. Anesth Analg (June) 90:1384-9, 2000 VASPain Time (min) 20 ml 0.08% Ropiv or Bupiv + 2  g/ml Fent

“Ambulatory” Labour Epidural Analgesia: Bupivacaine versus Ropivacaine Campbell DC, Zwack RM, et al. Anesth Analg (June) 90:1384-9, ml 0.08% Ropiv + 2  g/ml Fent ª Effective Labour Analgesia <10 min: (NS) ª100% Ambulation at 30 min (P< 0.03) ª100% Void Spontaneous (P< 0.01) ª Fewer Forceps (P< 0.05)

CSE VS LEA ½ Rapid Onset ½ “Walking Epidural” ½ PDPH ½ Epidural Catheter for Supplemental Analgesia. ½ Epidural Catheter for Surgical Anesthesia.

 Double Jeopardy-Double Risk (Two Needles)  Compared to spinal analgesia?  Compared to epidural analgesia? Lower incidence of PDPH in CSE?

CSE VS LEA ½ Rapid Onset ½ “Walking Epidural” ½ PDPH ½ Epidural Catheter for Supplemental Analgesia Technical Issues

Epidural needle Spinal needle Needle-through-needle technique

Disadvantage No separation of spinal and epidural route

P. D. W. Fettes et al. (Br J Anaesth, 97:359–364, 2006) Evidence is presented that intermittent boluses of local anesthetic in labor are more effective than continuous infusions. Intermittent vs Continuous Administration of Epidural Ropivacaine With Fentanyl for Analgesia During Labour.

CSE OR LEA? ½ “Walking Spinal” for minutes max. ½ Where is the Epidural catheter?? ½ You want how much for that Spinal Needle? “Walking Epidural” via Ropivacaine + Fentanyl Low Concentration/Fractionated = Safe Effective Labour Analgesia  Effective Surgical Anesthesia

Ideal labour analgesia ? Mother Fast, effective, continuous analgesia; mobility & 2 nd stage pushing.

Ideal labour analgesia ? Obstetrician No effect on labour outcome.

Ideal labour analgesia ? Neonatologist No effect on neonatal outcome.

Ideal labour analgesia ? Anaesthetist All the above + no side effects, complications, risks.

Fight is on! Join in!

Dr. Fatma Al Dammas