labor epidural

So how to do labor epidural that will cover both stages of labor?(about  pain at 2 stages of labor please see page “2 ways of pain during labor”)

thats how:

(rare video when wired catheter ends up intravascular and needs to be replaced)


We need CSE (combined spinal epidural ) with sacral block with hyperbaric tetracaine.

epidural will cover 1st stage, spinal 2nd stage.

and now–explanation

in our discussion you will see be talking about different options—what is available , and what is better, and why we do what we do.

1)so they page me for epidural, i come and  see woman in  pain.

Two options—if pain is tolerable and she CAN sit for epidural we procede,

if pain is not tolerable and she can NOT sit for epidural what do we do? We give Terbutaline 100mcg IV .

Why?  it is short acting tocolytic, so its going to stop labor for 10 min —enough time to place epidural. Some people suggest giving opioids (fentanyl 50 mcg). Our reason—pain in labor is caused by contractions , if we stop contractions—no pain.

Side effects of Terbutaline:  tachycardia  (its beta-agonist), and shakiness.

now we stoped the labor and pain , woman can sit for epidural

2)      Why to sit?              can we do it like this


Lying on the side —is Not good—our hyperbaric spinal will not go to S2S4—she needs to sit for gravity to work.

3) if we can feel spine we go for it, if not we use ultrasond(thats how to do it)

thats what you are going to see–just dark midline from spinal processes:


4) We need to numb the skin and soft tissues:  Lidocaine or Chlorprocaine?


Lidocaine hydrochloride 2% (1.7ml ampule 10 each)                      OR                 Chloroprocaine 403 20 jpg

Most of people use Lidocaine , but it burns(see post….)

We use Chlorprocaine–it does not burn (its all about love)

5)  We need to sterilise the skin: Iodine or Chlorhexidine?



Iodine is Not good  —-potentially our epidural catheter is gonna stay for 3 days (30-50% risk of c-section) . Chlorhexidine gives 48h antiseptic protection—no skin infection. if i use Iodine after 3 days will be induration and pus around catheter, if Chlorhexidine—nothing

article  (a little science to prove it)

Chlorhexidine is future!!!

6)  We mix prepear Hyperbaric Tetracaine for sacral block

1 ml of 25% dextrose (sugar water)

Dextrose Injection USP Pre-filled Syringe     and 2 ml of 1% tetracaine  
(Why we mix? because they  stoped making it  hyperbaric)
and we ll have 8% dextrose solution and 0,666% tetracaine
and we going to use 0,6ml  (its 4mg of Tetracaine)
7) then we put epidural needle in
then spinal thru epidural and get spinal fluid
8) inject 0.6ml of hyperbaric tetracain in spinal fluid–for dense sacral block(and let her sit for 10-15 min)
9) put epidural catheter
which catheter to use ?  or
on the left —nylon catheter–NOT good,                       on the right Wired catheter -GOOD
What is the difference?
nylon catheter—stiff, pain on placement ,
10% of cases rips into epidural vein, then has to be replaced ,
on removal tip can be cut off,
can be kinked
(you can see blue epidural veins on the picture–if catheter goes there we have iv , not epidural)
wired catheter—SOFT, no pain on placement
NEVER goes to vein(no need for replacement)
can not be cut
can not be kinked
10) Test dose foe epidural catheter —-only needed with nylon catheters—no need with wired catheters—they never go to the vein
11) give 10ml 0,0625% bupivacaine thru epidural catheter
12) start PCEA (patient controled epidural anesthesia) pump
0,0625% bupivacaine, fentanyl 2mcg /ml
What do we have in the end?
Woman does not feel contraction(epidural working on T10L1) , her butt and vagina are very numb(spinal-sacral block with tetracaine) , legs feel tinglish, but she can move them.Everything between her legs is numb–she does not feel Foley insertion, does not feel vaginal exams , pushing will be pain free.
on taping–please see post–how to keep catheters for 3 days

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