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

2. 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.

3. IN THE NAME OF ALLAH THE MOST BENEFICIENT THE MOST MERCIFUL
FROM THE HOLY QURAN
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)

4. CONTENTS
Introduction
CSE
Epidural analgesia
Review articles

5. INTRODUCTION

6. Stages of Labour

7. Pain pathways during labor

8. 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.

9. 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.

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

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

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

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

14. 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

15. 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

16. Does a few minutes advantage in analgesic onset matter?

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

18. 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

19. Better Blocks
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.

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

21. 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,

22. 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.

23. 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.

24. 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.

25. 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) 14

26. Does a Walking” epidurals meant better in analgesic outcomes?

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

28. 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.

29. 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

30. ↓ PDPH has advantage over analgesia ?

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

32. 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

33. 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.

34. 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

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

36. 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

37. Other advantage
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.

38. Do a few advantages in CSE analgesia matter?

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

40. Fetal Heart Rate

41. Post-CSE NRFHR: FETAL BRADYCARDIA
1993 Cohen Anesth Analg 15% (11/73)
1994 Clark Anesth’logy 30% (9/30)
1997 Campbell DC Anesth’logy 15% (6/39)
1998 Gambling Anesth’logy % (72/400)
1999 Palmer Anesth Analg % (12/100) *
2000 Wong Anesth’logy 17% (28/67)
2001 Van de Velde Reg An Pain Man % (40/351) *
* 50% greater than Epidural

42. How does labour analgesia cause fetal bradycardia?

43. 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

44. 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

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

46. 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:

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

48. 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 % %

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

50. 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.

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

52. 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.

53. 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.

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

55. 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 % %
Vomiting % %
Hypotension < 10.0 % < 10.0 %
Dural Puncture % %
Blood Patch

56. 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

57. CSE: Technical failures
Spinal needle too short
Spinal needle tents dura mater
Incorrect epidural needle position
dura
lig.
Flavum
Rawal et al. Reg Anesth. 1997

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

59. LABORE EPIDURAL ANALGESIA

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

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

62. 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?
Bob Gaiser, Ted Cheek and Brett Gustche in Philadelphia

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

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

65. “Ambulatory” Labour Epidural Analgesia:
“Ambulatory” Labour Epidural Analgesia: Bupivacaine versus Ropivacaine Campbell DC,Zwack RM, et al. Anesth Analg (June) 90:1384-9, 2000
Prospective, Randomized, Double-Blind
40 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)

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

67. Effective Labour Analgesia <10 min: (NS)
“Ambulatory” Labour Epidural Analgesia: Bupivacaine versus Ropivacaine Campbell DC, Zwack RM, et al. Anesth Analg (June) 90:1384-9, 2000
20 ml 0.08% Ropiv + 2 g/ml Fent
Effective Labour Analgesia <10 min: (NS)
100% Ambulation at 30 min (P< 0.03)
100% Void Spontaneous (P< 0.01)
Fewer Forceps (P< 0.05)

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

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

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

71. Needle-through-needle technique
Spinal needle
Epidural needle

72. Needle-through-needle technique
Disadvantage
No separation of spinal and epidural route

73. Intermittent vs Continuous Administration of Epidural Ropivacaine With Fentanyl for Analgesia During Labour.
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.

74. CSE OR LEA? “Walking Spinal” for 60-120 minutes max.
Where is the Epidural catheter??
You want how much for that Spinal Needle?
“Walking Epidural” via Ropivacaine + Fentanyl
Low Concentration/Fractionated = Safe
Effective Labour Analgesia  Effective Surgical Anesthesia

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

76. Ideal labour analgesia ?
Obstetrician
No effect on labour outcome.

77. Ideal labour analgesia ?
Neonatologist
No effect on neonatal outcome.

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

79. Thanks
Dr. Fatma Al Dammas

80. THANK YOU