Transcript Hysterectomy

Intrapartum Epidural
Anaesthesia
Max Brinsmead MB BS PhD
May 2015
This talk will cover...
• Evidence for risks and benefits associated
with this method of analgesia in labour
• Recommended information for patients
• Indications and contraindications
• Recommended agents & techniques
• Observations required with epidurals
• Modifications to intrapartum care that are
recommended
Benefits and Risks of Epidural Anaesthesia
What is the Evidence?
• There has been only one RCT of epidural vs
placebo
• A study of 132 nulliparas published 1999 in
Spanish
• This found that the procedure…
– Is highly effective for 91% of women
– Shortens the 1st stage of labour
– Has no effect on second stage labour
– And no effect on any other birth outcome
Cochrane Systematic Review (2005)
• 17 studies involving 6664 women
• Epidural compared by RCT to “all other methods
of analgesia” (mostly narcotics)
• The procedure is significantly associated with…
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Much better pain relief
Longer second stage (WMD 19 min, CI 11-27 min)
More assisted births (RR 1.34, CI 1.12-1.50)
More need for oxytocin infusion in the 2nd stage (RR
1.19, CI 1.02-1.38)
Maternal hypotension (RR 58, CI 21-161)
Maternal fever (RR 4.37, CI 2.99-6.38)
Urine retention (RR 17, CI 4.8-60)
Urine incontinence postpartum (but gone by 3m
and 12m)
Cochrane Review of RCT’s (2005)
• Found no significant differences in…
• Any measure of baby outcome
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Low cord pH
Apgar scores
Admission to SCN
Less Naloxone required
• Rate of Caesarean birth
• Women’s satisfaction with pain relief and their birth
experience
• Length of first stage of labour
• Perineal trauma
• Headache
• Long term back ache
• Breast feeding
What about Walking Epidurals?
• I have yet to encounter a patient walking
about after an intrapartum epidural
• A Cochrane meta analysis (2005) of the 4 –
7 trials that used only modern low dose
anaesthetic agents (≤0.25% bupivicaine or
equivalent) in 4324 women found…
• Substantially the same outcomes i.e…
– Longer second stage
– Fewer spontaneous births
– More oxytocin augmentations
Are Epidurals better for Babies?
• A systematic review of 8 RCT’s, 2268
women and 2 non-RCT’s, 185 women
• Umbilical artery pH significantly better after
epidural anaesthesia (WMD=0.009, CI 0.002-0.015)
• As was Base Excess (WMD=0.779 mEq/L)
• This implies better placental perfusion and
placental gas exchange
Do Epidurals affect the mechanism of birth?
• A prospective cohort study in the US
published 2005
• 1439 women with epidural compared to 123
without
• Head position studied using ultrasound at the time
of recruitment, beginning and end of second stage
of labour
• Corrected for other factors including the reason for
the epidural
• Epidural anaesthesia was associated with an
increased rate of persisting OP (but not OT) position
(12.9% vs 3.3% or OR 3.5, CI 1.2-9.9)
Is PCA Narcotic Analgesia a substitute for
Epidural Anaesthesia in Labour?
• Most studies confirm the findings of
Epidural CF all “other forms of analgesia”
• Pain scores are significantly lower after
epidural but maternal satisfaction is the
same
• One RCT of 715 women in the US showed
longer 1st stage labour after epidural (WMD
1.2 hrs)
• This could be overcome by using oxytocin
infusion
Common side effects of Epidural
• IV access required as hypotension can
occur
• About 10%
• Counteract with IV fluids, rarely pressors
• Pre-loading with IV fluid no longer required
before modern dose regimens
• At least 50% of patients require bladder
catheter
• Up to 66% patients given opioids in the
epidural will experience pruritis
• Nausea and shivering less common
Rare Complications of Intrapartum Epidurals
• Accidental dural tap
• Rate depends on operator experience (0.5 – 1%)
• At least 50% associated with severe headache
• And 25 – 30 % require a blood patch
• Accidental intravenous injection of agent
• Accidental spinal block
• Total paralysis & profound CVS collapse reverses over time
• Epidural haematoma
• Platelet count desirable in at-risk patients e.g. pre eclampsia
• Infection
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Catheter site infection
Meningitis
Epidural abscess
Meticulous site care required and timely removal
• Neurological injury
• It is very difficult to get incidence rates for the above
rare outcomes
• Lost catheter tip
What should women be told about Epidurals?
• NICE Recommendations
• Information about local availability
• It is more effective than other means of pain relief
• It is associated with a longer second stage and
reduced rate of spontaneous birth
• It requires IV access and increased maternal and
fetal monitoring
• This should not result in an increased rate of CS
• It does not cause long term back problems
• If the agent used contains an opoid then this can
reach the newborn with some effects
• My additions
• The risk of spinal tap is ≈1%
• There are other very rare risks and complications
Indications for Intrapartum Epidural
Anaesthesia
• Pain management in the first stage of
labour
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Spontaneous or induced labour
Rate then depends on patient request or
Availability of services
Ideally fully informed patients
And unlimited service by skilled anaesthetists
• Anaesthesia for 2nd and 3rd stage
interventions
• Assisted delivery and perineal repair
• Hypertension and seizure control for pre
eclampsia
Contraindications to Intrapartum Epidural
Anaesthesia
• High risk of haematoma
• Patient anticoagulated
• Platelet count ideally >100
– 50 – 100 is a grey zone (anaesthetists vary)
• High risk of sepsis
• Need for high anaesthesia, respiratory
assistance or unstable CVS system
• Placenta previa
• Relative contraindications
• Obesity
• Patient psyche
Best Techniques & Agents for Intrapartum
Epidural Anaesthesia
• Combined spinal-epidural best for rapid pain
control
• Use low dose bupivicaine e.g. 0.1% or less
with 2 ug/ml Fentanyl and boluses of 10 – 15
ml
• Patient controlled maintenance (PCEA) or
midwife administered top-ups result in lower
overall doses of agents
• And are preferred by patients
• Should be encouraged to adopt their degree of
block and position of choice for labour
When should an Epidural be inserted?
• There is evidence that lower doses of
analgesia are required if it commenced
sooner rather than later
• Some evidence of a shorter 1st stage labour
when epidurals are used early
• Women certainly appreciate it
• NICE recommends…
• “Women in labour who desire regional anaesthesia
should not be denied it, including women in severe
pain in the latent phase of the 1st stage”
NICE Recommended Observations after
Epidural
• BP every 5 min for 15 min after 1st block
and every top up
• Recall the anaesthetist if the woman is not
pain-free after 30 min
• Hourly assessment of level of block
• Otherwise routine maternal observations
• CTG during and for 30 min after 1st block
and every top up >10 ml
• ↓STV can occur
• Bradycardia can occur with intrathecal opiods
NICE Recommendations for management of the
2nd stage after Epidural
• Do NOT discontinue or reduce the anaesthesia
until the 3rd stage or perineal repair is
complete
• Use oxytocin when clinically indicated (not as a
routine)
• PUSH when…
• The mother wants to (and Cx is fully dilated)
• The head is visible
• Cx has been fully dilated for one hour
• Deliver within 4 hours of full dilatation
(regardless of parity)
Any Questions
or Comments?
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