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?
OR
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?
or 
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)http://www.nejm.org/doi/full/10.1056/NEJMoa0810988
Chlorhexidine is future!!!
6) We mix prepear Hyperbaric Tetracaine for sacral block
1 ml of 25% dextrose (sugar water)
and 2 ml of 1% tetracaine 
or
