Scholary discussion : thats how it looks like in scientific journal

Introduction of a novel technique for pain free labor

Blockade of second stage labor

Dr I.Kozlov , Dr M.Ackert

 Wyckoff Heights Medical Center 
374 Stockholm Street 
Brooklyn, NY 11237

Abstract

 

Traditional labor epidural techniques have not been proven to be sufficient to cover the second stage of labor. We have developed a technique that provides sufficient analgesia for second stage of labor. Potentially pain free labor could be achieved by using this method.   Utilizing hyperbaric Tetracaine intrathecally may provide a long lasting sensory sacral blockade.Primary outcome measure was absence of pain during pushing ( 2nd stage of labor). Sample size included all patients that requested labor epidurals  since 12/22/11 when this new technique was introduced.

Keywords: pain free labor, blockade of 2nd stage of labor, Combined Spinal Epidural (CSE),hyperbaric  Tetracaine, saddle block.

Methods

98 parturients received a Combined Spinal Epidural (CSE) technique in the sitting position with a 17 gauge Touhy needle, 27gauge Whitacre spinal needle and tetracaine 4mg in 8% dextrose (0.6ml of 0.66% solution). After successful placement of needles and epidural catheter, 10ml of 0.0625 Bupivicaine and Fentanyl 2mcg/ml was given and a patient controlled epidural analgesia (PCEA) was initiated. Patients were left in a sitting position for 20minutes in order for saddle block to settle, no discomfort was reported by patients during this period.  The effects of sacral block were evaluated by of absence of pain on Foley insertion, absence of discomfort on vaginal examination and need for local anesthetic for episiotomy or laceration repairs.Potential motor block was assessed by asking parturients to move their legs 30 min after CSE placement .For top-offs was used 0,25% bupivacaine 10 ml. Control group consistent of  52 parturients  where  in sitting position a 17 gauge Touhy needle was placed , epidural catheter inserted, and PCEA with 0,0625% Bupivacaine and Fentanyl 2 mcg/ml was initiated , 10 ml/h  , the demand dose was 10 ml q 30 min, its a standard technique used in our institution.

Results

 

22 patients whose labor ended in a C section were excluded from the study.  We found that of the remaining 76 patients there was 0/76 patients complaining of pain on Foley insertion, 0/76 patients complained of discomfort during vaginal exam, 0/76 patients complained of pain during second stage of labor.  No local anesthesia had to be administered for episiotomy or repairs. The duration of sacral block ranged from 2h to 12h. No motor block developed  30 min after CSE placement.

Length of Labor (Hours)

Number of Patients

Percentage

1

1

0,76%

2

7

5,32%

3

3

2,28%

4

11

8,36%

5

10

7,6%

6

7

5,32%

7

9

6,84%

8

7

5,32%

9

4

3,04%

10

9

6,84%

11

3

2,28%

12

5

3,8%

Conclusions

 

Utilizing 4mg of hyperbaric Tetracaine in a CSE technique provided excellent analgesia for both first and second stage of labor. A second benefit which was noted was the absence of pain during subsequent episiotomy repair.

Combined Spinal Epidural Anesthesia (CSEA) has become the preferred technique for providing analgesia to laboring parturients. There are various techniques involved with CSEA but the goals are rapid onset of analgesia, minimal motor blockade and high patient satisfaction. Utilizing a spinal needle in this technique has been shown to reduce epidural failure.

Traditional method of CSEA analgesia has been to administer a small amount of narcotic intrathecally. This results in good analgesia for the patient without motor blockade.  Disadvantages of this technique include pruritis, fetal bradycardia, no effect on second stage of labor, and short duration of action. A novel method for the intrathecal component is to administer a small amount of hyperbaric Tetracaine to create a sensory sacral block. The main advantages of this technique include fast onset of action and the ability to block the pain of second stage of labor with a long duration of action. Avoiding narcotics precludes the typical pruritis associated with the CSE.

Anesthesiologists traditionally have been able to provide effective relief during the first stage of labor but no practical method utilized can decrease pain during the second stage of labor. Anesthesiologists may have a blind spot concerning pain relief during the second stage of labor. This method addresses this blind spot.

Methods

After IRB approval and informed consent, 98 parturients with singleton, vertex presentation fetuses at 38-42 weeks gestation in active labor received CSE. The procedure was performed in the sitting position. The epidural space was identified with a 17g 8.5 cm Tuohy needle using loss of resistance technique.  A 27g Whitacre spinal needle was placed into the shaft of the epidural needle and upon confirmation of free flow CSF 4mg of hyperbaric Tetracaine was administered (.6 ml of 0.66% tetracaine in 8% dextrose).  A 20g epidural catheter was placed in the epidural space. After a negative aspiration for blood and CSF 10ml of 0.0625 % Bupivacaine and Fentanyl 2mcg/ml is given.  An infusion of the same solution is started at10ml per hour.  The demand dose is 10ml q 30 min.

 

 

 

The following questions were asked:

 

Ø      Did the patient feel any pain or discomfort during Foley insertion?

Ø      Was there a difference between vaginal exams before and after sacral block?

Ø      Was there any pain during pushing?

Ø      Was there any pain for episiotomy or laceration repair?

Ø      OBs and midwives were asked if local anesthetics were needed for episiotomy or laceration repair?

Results

 

22 parturientss whose labor ended in C-section were excluded from the study, because in c-section there is no 2nd stage of labor.  We found that of the remaining 76 patients, 0/76 patients complained of pain on Foley insertion, 0/76 patients complained of discomfort during vaginal exam, 0/76 patients complained of pain during the second stage of labor.  No local anesthesia had to be administered for episiotomy or laceration repairs.  The duration of sacral block ranged from 2 to 12 hours. In control group none of the patients  had relief of pain during Foley insertion, none of them had relief of discomfort during vaginal examination, all of them had pain during pushing, all of episiotomies or lacerations needed local anesthetic for repair, all of control group had pain if episiotomies or lacerations occurred.

Discussion

 

Traditional labor epidural techniques are not sufficient to cover the 2nd stage of labor.  Giving more local anesthetic thru the epidural catheter to create analgesia for 2nd stage of labor will inevitably cause motor blockade and the patient will not be able to push.  This prompted us to develop a technique that provides adequate sensory sacral blockade without a motor block.  This could be easily accomplished by administering 4mg hyperbaric Tetracaine for the spinal component of the CSE.  In these 76 patients there was absence of pain on Foley insertion, vaginal examinations, and during the complete 2nd stage of labor.  Further, no local anesthesia had to be administered for any episiotomy or laceration repairs.  We believe this technique warrants further evaluation.

Extended length of Tetracaine saddle block (6-12 hours) found in our case  can be explained combined use of PCEA with top-offs [1,2]

Refferences:

1. Anesthesiology. 2005 Nov;103(5):1046-51.

Dural puncture with a 27-gauge Whitacre needle as part of a combined spinal-epidural technique does not improve labor epidural catheter function.

Thomas JA, Pan PH, Harris LC, Owen MD, D’Angelo R.

Source

Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1009, USA.

2. Reg Anesth. 1990 Nov-Dec;15(6):275-9.

Sacralization of epidural block with repeated doses of 0.25% bupivacaine during labor.

Yarnell RW, Ewing DA, Tierney E, Smith MH.

Source

Department of Anaesthesia, Faculty of Medicine, University of Ottawa, Ontario, Canada.

3.  Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia.

Torvaldsen S, Roberts CL, Bell JC, Raynes-Greenow CH.

Source

Centre for Perinatal Health Services Research, Building DO2, University of Sydney, Sydney, 2006, New South Wales, Australia. siranda@perinatal.usyd.edu.au

4.  Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003401.

Combined spinal-epidural versus epidural analgesia in labour.

Simmons SW, Cyna AM, Dennis AT, Hughes D.

Source

Mercy Hospital for Women, 163 Studley Road, Heidelberg, Melbourne, Victoria, Australia, 3084. ssimmons@mercy.com.au

5.  Anesth Analg. 2008 Nov;107(5):1646-51.

A randomized trial of dural puncture epidural technique compared with the standard epidural technique for labor analgesia.

Cappiello E, O’Rourke N, Segal S, Tsen LC.

Source

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA.

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