Management of Labor Epidural: Tools of the Trade

1. Management of Labor Epidural: Tools of the Trade Dmitry Portnoy, MD Anesthesiology Department

3. Intensity of Pain in Labor

4. Physiology of Pain in Labor 1st stage of labor � mostly visceral Dilation of the cervix and distention of the lower uterine segment Dull, aching and poorly localized Slow conducting, visceral C fibers, enter spinal cord at T10 to L1 2nd stage of labor � mostly somatic Distention of the pelvic floor, vagina and perineum Sharp, severe and well localized Rapidly conducting A-delta fibers, enter spinal cord at S2 to S4

5. Anatomy of the Epidural Space Boundaries of epidural space Superior - the foramen magnum Inferior - the sacral hiatus and sacro- coccygeal membrane Anterior - the posterior longitudinal lig. Posterior - periosteum of laminae of the vertebrae and the lig. flavum Lateral - periosteum of the pedicles and intervertebral foraminae Epidural space contains: Dural sac and nerve roots Blood vessels and lymphatics Connective and fatty tissue

6.

7. Spread of Epidurally Injected Solutions Drugs must travel through: dura matter arachnoid matter CSF pia matter white matter gray matter Rapid access via �dural cuff� Competing pathways: Uptake into epidural epidural fat Uptake into systemic circulation

8. The Perfect Labor Epidural Safe (for both mother and fetus) Easy and painless placement Fast onset, easy administration, tight control Effective analgesia (for both stage I and II) Reliable extension for indicated procedures Minimal side effects (for both mother and fetus) No adverse effects on labor progress Minimal complications High patient satisfaction overall

9. Terms and Incidence of Unsatisfactory Epidural Block

11. Regional Anatomy and the Quality of Labor Epidural Effects of the anatomy on the successful placement of LEC Obesity, musculoskeletal abnormality, midline structures Details of the Ligamentum Flavum - midline gaps (failure to fuse) Effects of the geometry of epidural space on drug distribution Amount and distribution of fatty tissue Presence of midline structures plica mediana dorsalis (dura matris) - Luyendijk , 1963 midline adhesion of dura mater - Singh, 1967 epidural plica mediana dorsalis - Savolaine, 1988 dorsomedian connective tissue band - Blomberg, 1986 Spinal nerve root diameter - Galindo, 1975

12. Etiology and Contributing Factors Technique, methodology and equipment  Initial catheter misplacement - incorrect placement Malposition in anterior or paravertebral (lateral) epidural space Transforaminal escape Increased skin-to-epidural space distance Catheter related Catheter migration after initial proper placement The distance of insertion inside the epidural space Uniport versus multiport epidural catheters Catheter malfunction and catheter defects Air for loss-of-resistance technique Method of injecting local anesthetic Patient�s position

13. Etiology and Contributing FactorsPatient-related and other risk factors Inherited and acquired anatomical features Morbid obesity and body mass index greater than 30 Short and tall individuals Previous spinal surgery and a variety of musculoskeletal disorders History of a previous placement of epidural catheter Radicular pain during epidural placement Posterior presentation of the fetus Inadequate analgesia from the initial dose Duration of labor more than 6 hours Technical skills, or performance factors

14. Successful Management of Labor Epidural Preoperative considerations and planning ahead Initial placement of LEC � methodology and equipment Assessment and monitoring of LEA Management of existing epidural catheter Extension of LEA for indicated procedures Postpartum management of epidural catheter

15. Preoperative Considerations Maternal & Obstetric Factors: Nulliparity Earlier placement of LEA Heavier fetal weight Abnormal fetal presentation Dysfunctional labor Planning Ahead: Patient�s expectations Choice of LEA vs CSE Patient controlled technique Other technical issues Tailoring to high risk patient

16. Initial Placement of LEC Positioning of the patient and � the operator Identification of the landmarks Thorough local infiltration (start with 25g needle) Loss of resistance technique (to air vs NS) Length of LEC inside the epidural space Problem solving during the placement of an epidural Unable to identify midline (position? landmarks?) Unable to identify epidural space (position? landmarks? needle?) Unable to thread the catheter (true space? opened space?)

17. The perfect epidural puncture ?!? 

18. Assessment of the Quality of Labor Epidural Know the baseline Pain score Assessment of the sensory level Assessment of motor blockade (Bromage score) Degree of sympathetic blockade

19. Unsatisfactory Labor Epidural AnalgesiaManagement Options Catheter manipulation Additional volume of local anesthetic Patient�s position manipulation Replacement of the epidural catheter A single shot spinal anesthesia Continuous spinal anesthesia Combined spinal-epidural anesthesia Placement of an additional epidural catheter Supplementation with intravenous medications

20. Management of Unsatisfactory Epidural

21. Management of Unsatisfactory Epidural (cont)

22. Labor Epidural Pearls (Humble Suggestions) No labor epidural is worth the complications Do not insist unless medically indicated Consider other pain control options if LEA seems to be risky Give parturient realistic expectations Consider labor dynamics Constant communication during the procedure Any LOR is true unless otherwise proved Taping job is as important Do not give more than 3 cc of LA per 1.5 min Treat every dose as a test dose

23. Epidural Pearls (Humble Suggestions) � cont. The longer the skin-to-epidural distance, the deeper the catheter goes inside the space Routinely place LEC 3-4 cm into the epidural space Avoid placing the LEC longer than 6 cm into the space Do not allow the level to recede Avoid hypotension No LA with instant onset (not even close to) unless . . . Consider CSE

24. HAPPY EPIDURALS FOR ALL OF US!