Alternative techniques to labour epidural analgesia

Many systemic techniques, so-called "alternatives" to labor epidural analgesia, have been described: they are all poorly effective and some are associated with significant maternal and neonatal side effects. Nonetheless, these techniques can provide good maternal satisfaction. Accordingly, they are indicated when epidural analgesia is contraindicated or unavailable. Administration of systemic opioids mandates maternal respiratory supervision, oxygen supplementation and/or pulse oxymetry. Systemic opioids may also decrease fetal heart rate variability and produce neonatal respiratory depression; naloxone administration to the neonate is therefore widely indicated. Pethidine should be abandoned because it can produce prolonged neonatal respiratory depression. Nalbuphine produces less nausea/vomiting and less long lasting neonatal respiratory depression. Intravenous PCA fentanyl or sufentanil is presently the method of choice during early labor. Alfentanil seems less effective and may produce more neonatal side effects. Intravenous PCA remifentanil is the most effective technique, but safe administration may be problematic during intermittent supervision usually implemented in labour ward. Nitrous oxide 50% provides little pain relief. Nonetheless, it is associated with few side effects, quite good maternal satisfaction and can be quickly implemented during advanced painful labor. It is not recommended to add it to systemic opioid (except under continuous supervision by the anaesthetic team), because of an increased incidence of maternal desaturation. The use of a subanaesthetic concentration of sevoflurane has been described recently; it is more effective than nitrous oxide. However, guidelines for safe implementation in labor ward remain to be determined.     

硬膜外分娩镇痛的研究进展

硬膜外分娩镇痛对分娩的影响一直存在争议.新近资料不仅提供了硬膜外分娩镇痛对产程、剖宫产率、阴道器械助产率、及新生儿影响的进展,而且它与持续性枕后位和产妇发烧的关系也受到关注.改进硬膜外分娩镇痛技术的关键是减小对分娩不利影响并保证产妇满意镇痛的重要手段.研究表明采用低浓度局麻药复合阿片类药硬膜外镇痛,设置大容量PCEA和长锁定时间的输注模式对分娩的影响最小.     

Maternal postures and epidural analgesia during labour

The evolution of birth is of interest for obstetricians and midwives. Postures with asymmetric stretching and balance, kneeling, or sitting have been claimed to be able to help foetal head rotation. Although walking during labour have no influence on the outcome of labour, hip-flexed postures enlarging the pelvic diameter are yet evaluated to improve the obstetric course of labour. In a prospective randomised study including 93 parturients, we compared the supine 30 degrees lateral tilt (control group) to three hip-flexed postures: sitting (S), right hip-flexed left lateral position (L) and left hip-flexed right lateral position (R). Epidural analgesia with 12 ml ropivacaine 0.1% and sufentanil 0.5 microg/ml was administered over a period of six minutes. The total epidural spread was 15+/-0.3 dermatomes and the upper level of thermo-analgesic blockade reached T7-T8 (T5 to T10) in each group. There were no differences between groups for the left and right total spread and upper level of epidural blockade, for the time to maximal block and pain relief. There was no motor block and no maternal or foetal side effects. We conclude that, for the three hip-flexed postures tested, position does not influence local anesthetic spread or symmetry of analgesia after induction of obstetric epidural anaesthesia.     

Factors influencing backache following epidural analgesia in labour

262 obstetric patients received epidural analgesia during labour or for delivery. 6-8 weeks post partum they received a postal questionnaire. No association was found between backache and maternal age, height, weight, parity or mode of delivery, operator or difficulty with epidural insertion. However, in women who had had epidural analgesia, post-partum backache was associated with shorter labours. Difficult epidural insertions were more common in short women.     

Cerebrospinal fluid cutaneous fistula after labour epidural analgesia

We report a case of cerebrospinal fluid cutaneous fistula in a previously healthy patient who had seemingly uneventful lumbar epidural analgesia for labour.     

Spinal epidural abscess--a rare complication after epidural analgesia for labour and delivery

We report a case of spinal epidural abscess formation aftershort-term epidural catheter placement for analgesia duringlabour and delivery. The patient was previously healthy anddid not have any predisposing factors. Increasing back painwas the only complaint. A contrast-enhanced CT study on day5 was inconclusive. Magnetic resonance imaging was performedand showed a large triangular-shaped abscess with adjacent inflammationof the paravertebral muscles. One day later, the patient developeda sensory deficit in the left lower limb. The neurological deficitcompletely resolved after surgical decompression and debridement,which was followed by antibiotic treatment. Br J Anaesth 2004; 92: 896–8     

Complications of epidural and combined spinal-epidural analgesia in labour

AIM: The practice of relieving pain during childbirth with epidural or combined spinal-epidural analgesia is very widespread in the major Western countries, and is increasing in Italy. There are, however, numerous complications of this practice for both the woman and the mechanism of the labour. The aim of our study was to evaluate the short and long term complications of these techniques in a randomised sample of women. METHODS: A randomised, longitudinal, retrospective study was carried out in a sample of caucasian nulliparous women who gave birth in the second half of 2001. The subjects were divided into 3 groups: Group 1, women who gave birth with the aid of epidural analgesia; Group 2, women who received combined spinal-epidural analgesia during labour; Group 3, women who delivered without any analgesia. The short and long term complications of the 2 analgesic techniques were compared with those occurring in the control group, using Fisher's exact test. RESULTS: The frequency of at least one unwanted effect was higher in the 2 groups of women who received analgesia than in the control group. Hypotension and pruritus were statistically significantly more frequent in the group receiving spinal-epidural analgesia than in the other 2 groups. There were no statistically significant differences between the 3 groups in the rates of late complications or incidence of deliveries completed by cesarean section. CONCLUSIONS: The short-term complications of the analgesic techniques used during labour were not very relevant with respect to the subjects' satisfaction (excellent in 66% of the women in the group managed with epidural analgesia and 73% among those treated with the combined spinal-epidural technique). There was not a statistically significant difference in the percentage of cesarean deliveries in the 3 groups. Epidural and spinal-epidural analgesia to relieve pain during labour can, therefore, be considered safe and reliable.