Obstetrics Book

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Epidural Anesthesia

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  1. Indications
    1. Contractions regular and strong
    2. Fetal head engaged
    3. Adequate cervical dilatation
      1. Multiparous: Cervix dilated to 4-5 cm
      2. Nulliparous: Cervix dilated to 5-6 cm
  2. Technique
    1. Insert indwelling catheter into epidural space
      1. Gauge: 19-20
      2. Insertion Site: L3-4 interspace with Touhy Needle
      3. Elevate head of bed 20-30 degrees
    2. Early active phase
      1. Bupivacaine 0.25% 6-8 ml every 1 to 1.5 hours
      2. Spinal level: T10 to L1
    3. Later first stage to early second stage
      1. Bupivacaine 0.25% 8-12 ml every 1 to 2 hours
      2. Spinal level: T10 to S5
    4. New low-dose epidural protocol
      1. Lower dose anesthetic with Fentanyl
      2. Allows patients to remain ambulatory despite epidural
      3. Similar pain relief to standard epidural
      4. Lower initial APGAR Scores, but similar outcomes
      5. Small study showed significant benefits
        1. Higher normal vaginal delivery rate
        2. Lower instrumented delivery rate
        3. Shorter second stage of labor
      6. Reference
        1. (2001) Lancet 358:19
  3. Adverse Effects
    1. Risks of maternal hypotension
      1. Give concurrent Intravenous fluids
    2. Systemic injection
      1. Stop if Dizziness or Tinnitus after test dose
    3. Mixed data on labor progress and outcomes
      1. Higher risk of Labor Dystocia if cervix <5 cm
        1. Early epidural: 21% Cesarean section rate
        2. Late epidural: 11% Cesarean section rate
        3. Reference
          1. Lieberman (1995) Perinatal Confer, John's Hopkins
      2. More recent study shows no benefit to epidural delay
        1. Labor slowed only between 4-5 cm (not <4 cm)
        2. No increase in ceserean with early epidural
        3. Vahratian (2004) Am J Obstet Gynecol 191:259

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