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Initiation and Maintenance of Labour Analgesia: Epidural or
CSE, Bolus or Infusion?
Dr Vinnie SodhiClinical Lead for High Risk Obstetric Anaesthesia
Queen Charlotte’s and Chelsea HospitalLondon
A brief history…..Genesis 3:16
l God said to Eve
“ I will make your pains in childbearing very severe; with painful labour you will give birth to children”
l >1800 years religious opposition to labour analgesia
Journey of analgesia in obstetrics:l 19th century increased use of chloroform and ether
l Various techniques for obstetric regional analgesia (RA) described 1900-‐1930
l Continuous RA (caudal) – Hingson and Edwards, 1943
l 1950s-‐present: Lumbar epidural and Combined spinal-‐epidural (CSE)
Modern Labour Analgesia:
l When?
l How?
l With what?
Initiation of RA for labour: when?l ?Increased CS rate with early initiation
l >1200 women randomised to receive epidural analgesia at 1 or 4 cm dilatation
l No effect on progress or outcome of labour
l RA should be established at maternal request including in latent phase
Wang FZ et al, 2009. Anesthesiology 111: 871-‐880
Initiation of labour analgesia: How? With what?l Lumbar epidural:
-‐ 20 mls x 0.1% plain bupivacaine + 40 mcg fentanyl
l Combined spinal-‐epidural (CSE):
-‐ needle-‐through-‐needle / separate space
-‐ Intrathecal plain bupivacaine 2.5 mg + 5-‐25 mcg fentanyl
Common indications for CSE:l Severe maternal distress regardless of cervical dilatation
l Rapid analgesia in late first stage and second stage of labour
l Anaesthesia for delivery (2nd stage)
l Anaesthesia for artificial rupture of membranes (ARM)
l Multiparae in established labour
l Previous suboptimal analgesia with lumbar epidural
l Difficult back
Disadvantages of CSE for labour analgesia?
l No evidence for increased risk of infection with scrupulous asepsis
l CSE no higher than L3/4 interspace to avoid neurotrauma
l No increase in PDPH with CSE
FHR abnormalities and intrathecal opioids:l CSE – sudden drop in pain level => decrease adrenaline and β-‐endorphin
l No decrease noradrenaline or oxytocin
l Vasoconstriction and uterine hypertony
l ? Additional central effect
l ? Dose dependent effect
l No effect on maternal and neonatal morbidity
l ? Avoid when fetal distress or uterine hypertonypresent prior to labouranalgesia
Disadvantages of CSE for labour analgesia
l Intrathecal opioid – increased pruritus
l Dose dependent effect
Initiation of labour analgesia: CSE or epidural?
l “No conclusive evidence to recommend one technique over another…”
Simmons SW et al, 2012. Cochrane Database Syst Rev (10):CD003401
Maintenance of Labour Analgesia: Low dose mixturesl 1970s : use of low concentration LA in large volumes
l 1980s : addition of opioid prolonged duration and improved quality of analgesia
l Minimal motor block
l No effect on progress of labour
Maintenance of labour analgesia: Choice of Local Anaestheticl Bupivacaine vs levobupivacaine vs ropivacaine
l MLAC Bupivacaine > levobupivacaine /ropivacaine
l Greater safety of single enantiomers
l Choice of LA does not appear to affect outcome of labour
Halpern and Walsh(2003). Anesth Analg 96:1473-‐1479
Maintenance of labour analgesia: the ideal techniquel Continuous, uninterrupted and safe analgesia
l Titration of dose to progress of labour and pain
l Allow maternal ambulation
l Allow effective pushing in 2nd stage
l No breakthrough pain
l Decrease total anaestheticdose
l Decrease physician workload
Techniques available:l “Interrupted”
-‐ Manual top ups (midwife/anaesthetist)
-‐ Patient controlled epidural analgesia (PCEA)
l “Continuous”
-‐ Continuous epidural infusion (CEI)
-‐ PCEA with background infusion
-‐ Automated Mandatory Boluses (AMB)/ Programmed Intermittent Boluses (PIB)
-‐ Computer integrated PCEA (CI-‐PCEA)
Intermittent epidural bolus (midwife top-‐up):
Prosl Titrate dose and volume to progress of labour and severity of pain in individual
l Less frequent motor block
l Less LA consumption
Consl Midwife involved
l Pain free intervals only
l Time to re-‐establish analgesia
l Delay in receiving top up if clinician delivered
l Increased workload
PCEA:Pros:
l Autonomy
l Titratability
l Reduced workload
l Safe
Cons:l ?Ideal bolus/lockout regimen
l Patient experiences intermittent pain
l Maternal cultural/psychological factors and expectations
l Technical problems with pumps
Continuous Epidural Infusion (CEI):Advantages
l True continuous pain relief
l Can be individualised and titrated
l Avoids block regression
l ? More CVS stability
Disadvantagesl “Automatic pilot”
l Breakthrough pain
l Increased motor block
l Increased urinary catheterisation
l Increased LA consumption
Maintenance of labour analgesia: Continuous infusion vs intermittent (top-‐up)Spread dependent on:
• Volume of injectate• Speed of injection• Pressure applied• Single or multiport catheter
PCEA plus background infusion:Pros:
l ? > 5 ml/hr Basal infusion better
l ?Decreased breakthrough pain
l => decreased workload
Cons:l Increased LA consumption
l Increased motor block
l No clear evidence of improvement in maternal analgesia and satisfaction
PCEA plus AMB: Double pump systemAMB:
l Variant of PCEA+CEI
l Infusion dose given as bolus at set intervals
l Decreased need for self boluses
l Decreased motor block
l Decreased instrumental delivery
Double pump system:
PCEA + PIB: “Smartpumps”The “Smartpump” AMB/PIB
l Fixed preprogrammed epidural bolus at regular intervals with PCEA/clinician bolus for breakthrough pain
l Lockout time between PIB/PCEA bolus
l Single drug mixture only
Computer-‐integrated PCEA (CI-‐PCEA):l Software programme and pump in development based on new clinical algorithm
l Target is to adjust background infusion rate according to frequency of earlier demands
l Matches basal infusion rate to patient’s analgesic needs
My conclusions: CSE or epidural?Depends on:
l Mother’s needs
l Safety of mother and baby
l Expertise within the unit
Bolus or infusion:
l Dependent on logistics
l Bolus – midwife or PCEA
l 8-‐10 ml LDM every 15-‐20 minutes
l Further research to achieve ideal
Acknowledgements:
References 1l *Bauer ME et al. Risk factors for failed conversion of labor epidural analgesia to cesarean delivery anesthesia: a systematic review and
meta-analysis of observational trials. Int J Obstet Anesth 2012;;21:294-309
l Boswell O et al. The use of obstetric patient-controlled epidural analgesia: a survey of labour wards across the UK. Int J Obstet Anesth2007;;16:S39
l BurnsteinR et al. A survey of epidural analgesia for labour in the United Kingdom. Anaesthesia 1999;;54:634-40
l CapognaG et al. Programmed intermittent epidural bolus versus continuous epidural infusion for labor analgesia: the effects on maternal motor function and labor outcome. A randomized double-blind study in nulliparous women. AnesthAnalg 2011;;113:826-31
l *CapognaG et al. Techniques for the maintenance of epidural labor analgesia. Curr Opin Anaesthesiol2013;;26:261-7
l *Cappiello E et al. A randomized trial of dural puncture epidural technique compared with the standard epidural technique for laboranalgesia.AnesthAnalg 2008;;107:1646-51
l CascioM et al. Meningitis following combined spinal-epidural technique in a labouring term parturient. Can J Anesth 1996;;43:399-401
l Christiaens F et al. Effects of diluent volume of a single dose of epidural bupivacaine in parturients during the first stage of labour. RegAnesthPain Med 1998;;23:134-41
l Collis RE et al. Combined spinal epidural (CSE) analgesia: technique, management, and outcome of 300 mothers. Int J Obstet Anesth1994;;3:75-81
l *COMET Study Group UK. Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial. Lancet 2001;;358:19-23
References 2l Cooper GM et al. Satisfaction, control and pain relief: short- and long-term assessments in a randomised controlled trial of low-
dose and traditional epidurals and a non-epidural comparison group. Int J Obstet Anesth 2010;;19:31-7
l D’Angelo R et al. A comparison of multiport and uniport epidural catheters in laboring patients. Anesth Analg 1997;;84:1276-9
l Gambling DR vsBogod D. Epidural infusions in labour should be abandoned in favour of patient-controlled epidural analgesia.Int J Obstet Anesth 1996;;5:59-63
l Gambling D et al. A randomized controlled comparison of epidural analgesia and combined spinal-epidural analgesia in a private practice setting: pain scores during first and second stages of labor and at delivery. Anesth Analg 2013;;116:636-43
l *George RB et al. Intermittentepidural bolus compared with continuous epidural infusions for labor analgesia: a systematic review and meta-analysis.Anesth Analg2013;;116:133-44
l Goodman SR et al. A randomized trial of breakthrough pain during combined spinal-epidural versus epidural labor analgesia in parouswomen. Anesth Analg 2009;;108:246-51
l Griffiths S et al. Headache after combined spinal-epidural blocks: a ten year review. Int J Obstet Anesth 2013;;22:S55
l *Halpern SH et al. Patient-controlled epidural analgesia for labor. Anesth Analg 2009;;108:921-8
l *HeesenM et al. Meta-analysis of the success of block following combined spinal-epidural vs epidural analgesia during labour. Anaesthesia 2014;;69:64-71
References 3l Hepner DL et al. Comparison of combined spinal-epidural and low dose epidural for labour analgesia. Can J Anaesth 2000;;47:232-6
l Hess PE et al. Predictors of breakthrough pain during labor analgesia. AnesthAnalg 2001;;93:414-8
l *Kaynar AM et al. Epidural infusion: continuous or bolus? AnesthAnalg 1999;;89:534
l Lee S et al. Failure of augmentation of labor epidural analgesia for intrapartum cesarean delivery. AnesthAnalg 2009;;108:252-4
l Leo S et al. A randomized comparison of automated intermittent mandatory boluses with a basal infusion in combination with patient-controlled epidural analgesia for labor and delivery. Int J ObstetAnesth2010;;19:357-64
l Leo S et al. Maintaining labour epidural analgesia: what is the best option? Curr OpinAnaesthesiol2008;;21:263-9
l Lim Y et al. Automated regular boluses for epidural analgesia: a comparison with continuous infusion. Int J ObstetAnesth 2005;;4:305-309
l *Loubert C et al. Update on modern neuraxial analgesia in labour: a review of the literature of the last 5 years. Anaesthesia 2011;;66:191-212
l Lyons GR et al. Extradural pain relief in labour: bupivacaine sparing by extradural fentanyl is dose dependent. Br J Anaesth 1997;;78:493-7
References 4l *MardirosoffC et al. Fetal bradycardia due to intrathecal opioids for labour analgesia: a systematic review. Br J Obstet
Gynaecol 2002;;109:274-81
l *Niesen AD et al. Combined spinal-epidural versus epidural analgesia for labor and delivery. Clin Perinatol 2013;;40:373-84
l Norris MC. Are combined spinal-epidural catheters reliable? Int J ObstetAnesth 2000;;9:3-6
l PaechMJ. Patient-controlled epidural analgesia in obstetrics. Int J ObstetAnesth 1996;;5:115-25
l PaechMJ et al. New recipes for neuraxial labor analgesia: simple fare or gourmet combos? Int J Obstet Anesth 2009;;18:201-3
l Palmer et al. The dose-response relation of intrathecal fentanyl for labor analgesia. Anesthesiology1998;;88:355-61
l Pan PH et al. Incidence and characteristics of failures in obstetric neuraxialanalgesia and anesthesia: a retrospective analysis of 19,259 deliveries. Int J ObstetAnesth 2004;;13:227-33
l Parpaglioni R et al. Minimum local analgesic dose: effect of different volumes of intrathecal levobupivacaine in early labor. Anesthesiology 2005;;103:1233-716
l Preston R. The role of combined spinal epidural analgesia for labour: is there still a question? Can J Anesth 2007;;54:9-14
l Shukla B et al. Practice of patient controlled epidural analgesia (PCEA) in obstetric units: a national survey of current practice. OAA Poster 2013
References 5l SiaAT et al. A comparison of a basal infusion with automated mandatory boluses in parturient-controlled epidural analgesia during labor. Anesth Analg 2007;;104:673-8
l *Simmons SW et al. Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database of Systematic Reviews 2012
l Skupski DW et al. Adverse effects of combined spinal-epidural versus traditional epidural analgesia during labor. IntJ Gynaecol Obstet 2009;;106:242-5
l Smiley RM et al. Patient-controlled epidural analgesia for labor. International Anesthesiology Clinics 2007;;45:83-98
l Thomas JA et al. Dural puncture with a 27-gauge Whitacre needle as part of a combined spinal-epidural technique does not improve labor epidural catheter function. Anesthesiology 2005;;103:1046-51
l Van de Velde M vs Benhamou D. Intermittent top-ups are better than continuous infusions for epidural analgesia in labour. Int J Obstet Anesth 2000;;9:259-63
l *Van der Vyver M et al. Patient-controlled epidural analgesia versus continuous infusion for labour analgesia: a meta-analysis. Br J Anaesth 2002;;89:459-65
l Wong CA et al. A randomized comparison of programmed intermittent epidural bolus with continuous epidural infusion for labor analgesia. Anesth Analg 2006;;102:904-9
l *Wong CA et al. The effect of manipulation of the programmed intermittent bolus time interval and injection volume on total drug use for labor epidural analgesia: a randomized controlled trial. Anesth Analg 2011;;112:904-11
