1. Epidurals and spinals: Is that all we have to offer for obstetrical pain?
Jill Cooley, MD
Department of Anesthesiology
University of Tennessee Health Science Center
Regional One Health

2. No Disclosures

3. -Describe role of Lumbar Epidural in Labor analgesia
Objectives
-Describe role of Lumbar Epidural in Labor analgesia
-Identify alternatives to neuraxial labor analgesia
-Discuss treatment options for acute post-cesarean pain control
-Identify risk factors for development of Chronic Pain
-Discuss practice measures for pain management in opioid crisis era

4. 600 B.C.

5. Lumbar Epidural -60% of deliveries -Continuous + PCEA - PIDB +/- PCEA
most common method of labor analgesia
-60% of deliveries
optimal method of delivery still questioned
-Continuous + PCEA
- PIDB +/- PCEA
- Dural Puncture for Sacral Spread
CSE-provider dependent

6. Remifentanil Dosing: PCA only, no background
delivery of 20-50micrograms per dose
optimal timing is dose delivery at onset of contraction
can titrate lockout of 2mins
Patient Variability
Additional monitoring/personnel
Potential for sedation, respiratory depression
Not approved; lacking established standard dosing

7. Nitrous Oxide -Cost effective -Good Safety Profile
-Viable alternative to neuraxial
-Implementation Obstacles
-diversion
-staff exposure -

8. Post cesarean pain management
Intrathecal
-Duramorph ug
-analgesia for up to 24hrs
-pruritus, nausea
-management of breakthrough pain
-Clonidine ug
-increased duration of sensory block, improved analgesia
-dose dependant hypotension reported
- Epidural clonidine 2-4mcg/ml % bupi for post operative pain control

9. Post cesarean pain management
Regional
Transverse Abdominal Plane
Quadratus Laborum
Field Infiltration

10. Transverse Abdominal plane block
-Less effective than ITM
-Improved analgesia when combined with ITM
-Consideration when ITM contraindicated
-Visceral Sparing
Continous catheter for hrs
Local Anesthetic Caution

11. Quadratus Lumborum -visceral? -more effective than TAP for analgesia
-Patient positioning more challenging
-multi-modal componant

12. OPIOID CRISIS -Pain management in opioid crisis
MMA, avoid the pain number, focus on function,
communicate expectations
-Poorly managed acute pain leads to chronic pain

13. Perception and Pain
-Identify patients with risk factors for development of chronic pain
-Compare what patient wanted to what they received

14. THE END

15. References:     
McKenzie CP, Cobb B, Riley ET, Carvalho B. Programmed intermittent epidural boluses for maintenance of labor analgesia: an impact study. Int J Obstet Anesth. 2016 May;26:32-8.  
Bonnet, M.P.; Prunet, C.; Baillard, C.; Kpéa, L.; Blondel, B.; Le Ray, C. Anesthetic and Obstetrical Factors Associated With the Effectiveness of Epidural Analgesia for Labor Pain Relief: An Observational Population-based Study. Obstetric Anesthesia Digest: December Volume 37 - Issue 4 - p 213 
 péa, L.; Bonnet, M.; Ray, C.; Prunet, C.; Ducloy-Bouthors, A.; Blondel, B.IInitial Preference for Labor Without Neuraxial Analgesia and Actual Use: Results from a National Survey in France. Obstetric Anesthesia Digest: September Volume 36 - Issue 3 - p 157–158 
Heesen, Michael; Böhmer, Johannes; Klöhr, Sven; Hofmann, Thomas; Rossaint, Rolf; Straube, Sebastian.  The Effect of Adding a Background Infusion to Patient-Controlled Epidural Labor Analgesia on Labor, Maternal, and Neonatal Outcomes: A Systematic Review and Meta-Analysis. Obstetric Anesthesia Digest: June Volume 36 - Issue 2 - p 105–106 
 Richardson MG1, Lopez BM, Baysinger CL, Shotwell MS, Chestnut DH.   Nitrous Oxide During Labor: Maternal Satisfaction Does Not Depend Exclusively on Analgesic Effectiveness. Anesth Analg Feb;124(2):   
Tawfik MM1, Mohamed YM, Elbadrawi RE, Abdelkhalek M, Mogahed MM, Ezz HM. Transversus Abdominis Plane Block Versus Wound Infiltration for Analgesia After Cesarean Delivery: A Randomized Controlled Trial. Anesth Analg Apr;124(4):  doi: /ANE  
Eisenach, J.C., Pan, P.H., Smiley, R., Lavand’homme, P., Landau, R., and Houle, T.T. Severity of acute pain after childbirth, but not type of delivery, predicts persistent pain and postpartum depression. Pain. 2008; 140: 87–94 
Chong MA1, Wang Y2, Dhir S3, Lin C. . Programmed intermittent peripheral nerve local anesthetic bolus compared with continuous infusions for postoperative analgesia: A systematic review and meta-analysis  J Clin Anesth. 2017 Nov;42:69-76.