1. Safety and quality of neuraxial analgesia Ulla Sipiläinen 6.10. 2011 HUCS Jorvi hospital

2. Chestnut´s Checklist Preparation for neuraxial labor analgesiaPreparation for neuraxial labor analgesia 1.Communicate (early) with obst provider review parturient´s obst history 2.Perform focused preanesth eval: review maternal obst, anest, health history perform targeted physical exam (vital signs, airway, heart, lungs, back) 3.Review relevant lab and imaging studies

3. 4.consider need for blood typing and screening or crossmatching4.consider need for blood typing and screening or crossmatching 5.formulate analgesia plan5.formulate analgesia plan 6.obtain informed consent6.obtain informed consent 7.perform equipment check7.perform equipment check Check routine equipmentCheck routine equipment Check emergency recuscitation equipmentCheck emergency recuscitation equipment 8.Obtain peripheral intravenous acces 9.Apply maternal monitors ( Hr, BP, Pulseoximeter 10.Perform a team time-out.

4. Real life checklist Airway, airway, airway!Airway, airway, airway! Trombosytes, if symptoms of pre- echlampsiaTrombosytes, if symptoms of pre- echlampsia Position: BMIPosition: BMI AllergiesAllergies

5. maintain your skills wet tap rate / dural puncture ratewet tap rate / dural puncture rate teaching problematicteaching problematic formal training programme for epidural analgesia?formal training programme for epidural analgesia? simulator?simulator?

6. Position sitting/ on sidesitting/ on side weight>height-100, examp, 170cm, 80kgweight>height-100, examp, 170cm, 80kg consider sitting positionconsider sitting position

7. Skin preparation meningitismeningitis epidural infectionepidural infection wear mask, sterile gloves, hatwear mask, sterile gloves, hat skin preparationskin preparation infections are very rareinfections are very rare st viridansst viridans

8. early vs late epidural cervical dilatation less than 4 cmcervical dilatation less than 4 cm with low-dose local anesthetic techniquewith low-dose local anesthetic technique no difference in cs ratesno difference in cs rates C. Wong 2005 and 2009C. Wong 2005 and 2009

9. CSE vs epidural analgesia CSE when it is really neededCSE when it is really needed multiparous patients in advanced, rapidly progressing labourmultiparous patients in advanced, rapidly progressing labour even single-shot spinaleven single-shot spinal risk of cs, obese, very painfulrisk of cs, obese, very painful

10. Air vs Saline saline is recommendedsaline is recommended saline with small air bubblesaline with small air bubble in Finland air is most popularin Finland air is most popular no differences in the incidence if PDPH between saline or airno differences in the incidence if PDPH between saline or air

11. Continous vs intermittent pressure in loss of resistance syringepressure in loss of resistance syringe no differenceno difference personal preferencespersonal preferences

12. Volume high-volumehigh-volume low concentration solutionslow concentration solutions better analgesia with 20ml epidural than 13ml or 15mlbetter analgesia with 20ml epidural than 13ml or 15ml if one-sided or in-adequate analgesia, volume addition ad 5 ml before replacementif one-sided or in-adequate analgesia, volume addition ad 5 ml before replacement

13. PCEA, infusion, bolus? maintainingmaintaining volume!volume! second dose intructions for midwife: 20mlsecond dose intructions for midwife: 20ml PCEA best, large bolus are needed to spread widelyPCEA best, large bolus are needed to spread widely

14. Intra-venous epidural test dose!!test dose!! catether migrate into veins very easily and oftencatether migrate into veins very easily and often saline -injektion, aspirationsaline -injektion, aspiration important to detectimportant to detect

15. Obese partiturent greater risk for csgreater risk for cs epidural space?epidural space? lumbar space?lumbar space? position: sittingposition: sitting G18/G27 120mm needleG18/G27 120mm needle CSE or epiduralCSE or epidural favour early analgesia favour early analgesia

16. Taping flexed position minimizes the distance between skin and epidural spaceflexed position minimizes the distance between skin and epidural space the catether can move up to 4 cmthe catether can move up to 4 cm leave the catether 5-6 cm into the epidural spaceleave the catether 5-6 cm into the epidural space

17. Routines routines protect from mistakesroutines protect from mistakes variation between phycisiansvariation between phycisians analgesia similar undependantly from person on callanalgesia similar undependantly from person on call

18. Incidence and chaceterics of failures in obstetr analgesia Retrospective analysis of 19 259 deliveriesRetrospective analysis of 19 259 deliveries 12 590 analgesia12 590 analgesia Overall failure rate 12%Overall failure rate 12% 6.8 % imcomplete analgesia6.8 % imcomplete analgesia 5.6% catether replacement for inadequate analgesia5.6% catether replacement for inadequate analgesia 98.8% adequate analgesia98.8% adequate analgesia Pan P. et al Int J Obst Anest 2004:13; 227-233Pan P. et al Int J Obst Anest 2004:13; 227-233

19. Inadequate analgesia Consider other causes of pain: distended bladder, ruptured uterusConsider other causes of pain: distended bladder, ruptured uterus Evaluation: catether in epidural space? - > not-> replacement or consider CSEEvaluation: catether in epidural space? - > not-> replacement or consider CSE Inadequate analgesia, asymmetric block-> inject saline 5mlInadequate analgesia, asymmetric block-> inject saline 5ml CSE has lower failure rate than epiduralCSE has lower failure rate than epidural

20. Intrathecal catether important to detectimportant to detect test dose always via catethertest dose always via catether immediate analgesiaimmediate analgesia total spinal anaesthesia may be disasteroustotal spinal anaesthesia may be disasterous

21. Accidental dural puncture earlier: catether placed for 24 hrsearlier: catether placed for 24 hrs now: new epidural analgesia from another lumbar space and epidural blood patch if needed after 24 -36 hrsnow: new epidural analgesia from another lumbar space and epidural blood patch if needed after 24 -36 hrs delayd application of EBP may cause problems, be aware!delayd application of EBP may cause problems, be aware!

22. Neuraxial analgesia and neuraxial injury common claimcommon claim indirect injury: longer second stage of labourindirect injury: longer second stage of labour relaxation of pelvic muscles -> delays rotation of headrelaxation of pelvic muscles -> delays rotation of head no pain-> encourage to push without changing body positionno pain-> encourage to push without changing body position

23. Adverse delivery outcomes weakened desire to pushweakened desire to push increases the risk of instrumental deliveryincreases the risk of instrumental delivery risk of vaginal/ perineal traumarisk of vaginal/ perineal trauma back pain is common back pain is common

24. Recommendations instructionsinstructions also for potential complicationsalso for potential complications iv line, hydrationiv line, hydration hypotensionhypotension anesthesia for CSanesthesia for CS fastingfasting dural puncturedural puncture

25. Conclusion 1 ” Unreasonable to expect, that neuroblocade of the half lower body NOT have any affect on labour process.. ”” Unreasonable to expect, that neuroblocade of the half lower body NOT have any affect on labour process.. ” Chestnut`sChestnut`s

26. dose examples Ropivacaine 2 mg/ml 10mlRopivacaine 2 mg/ml 10ml Fentanyl 0.05mg/ml 2mlFentanyl 0.05mg/ml 2ml Saline ad 20mlSaline ad 20ml 2-dose, given by midwife:2-dose, given by midwife: 10ml ropivacaine10ml ropivacaine fentanyl 0.05mg/ml 1ml (Sic!)fentanyl 0.05mg/ml 1ml (Sic!) Saline 9ml, total dose 20ml.Saline 9ml, total dose 20ml.

27. dose examples CSE:CSE: Bupivacain 2.5mgBupivacain 2.5mg Fentanyl 25mcgFentanyl 25mcg saline ad 2mlsaline ad 2ml

28. Conclusion Instructions for own hospitalInstructions for own hospital Analgesia should be given early enoughAnalgesia should be given early enough Does not increase cs rateDoes not increase cs rate

29. Thank you!