Barbaric stage of OB anesthesia

Barbarians….why barbarians ?


What makes barbarians different from civilised people?Barbarians have 2 problems –in their head and in their heart.In their head –they do not know how to reason, and in their heart—they are cruel , they do not care about others, they do not know how to love(man in the picture does not appear loving and ready to reason and reflect).I need both . Because without reason i am just an idiot, i am not different from an animal, but if i know how to reason , but do not love–i ll be cruel, a cruel Nazi. (check this out)


Reasoning without love is brutality, cruelty.

st Paul says:”Without love i am nothing” (1 Cor ch 13)

(it seems to be, if i reflect on it,that if i go to medical school but do not know how to love –i ll be a little nazi.  No good.)

So, why we say :”OB anesthesia in the BARBARIC stage?”

Usual traditional  labor epidural does not cover second stage of labor. Woman will have pain relief from  contractions , but when she is fully dilated and ready to push —she ll scream.Anesthesiologist are not even bothered that women are in pain in second stage(no heart), or if bothered they face unresolvable dilemma —if they give enough local anesthetic thru epidural(2% lidocaine) woman will be pain free but paralysed and unable to push, if they do not give anything she ll be in pain. They do not reflect how to solve this dilemma(no head). And we know now that without head and heart you are just a barbarian.

What is the solution—CSE with sacral block with hyperbaric tetracaine. No pain and can push.



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Why lidocaine burns and why fever during epidural

Epidural during labor causes  fever , temperature goes up. Mechanism was not found yet. We found possible mechanism on Wikipedia. God bless Wikipedia.

Another problem—local anesthetics burn on injection(when you go to  your dentist–it burns when he shoots you).Why? Feeling of burning is mediated thru vanilloid receptor(TRPV1) .Anything that burns has to work thru  vanilloid receptor (pepper , garlic, mace, acid). Menthol blocks it.Besides pain this receptor is is excited by high temperature too—thats why cooling bruise with ice will reduce pain—its the same receptor.

TRPV1 is the most popular, pepper works thru  that

so Lidocaine when injected works on this receptor, stimulates it and causes pain (and blocks it after.

antagonist of this receptor are proved to cause hyperthermia:(same wikipedia page)

Antagonists block TRPV1 activity, thus reducing pain. These agents could be useful when applied systemically.[8] Numerous TRPV1 antagonists have been developed by pharmaceutical companies. TRPV1 antagonists have shown efficacy in reducing nociception from inflammatory andneuropathic pain models in rats.[9] This provides evidence that TRPV1 is the capsaicin‘s sole receptor.[10] In humans, drugs acting at TRPV1 receptors could be used to treat neuropathic pain associated with multiple sclerosischemotherapy, or amputation, as well as pain associated with the inflammatory response of damaged tissue, such as in osteoarthritis.[11]

The major roadblock for the usefulness of these drugs is their effect on body temperature (hyperthermia). The role of TRPV1 in the regulation of body temperature has emerged in the last few years. Based on a number of TRPV-selective antagonists‘ causing an increase in body temperature (hyperthermia), it was proposed that TRPV1 is tonically active in vivo and regulates body temperature[12] by telling the body to “cool itself down”. Without these signals, the body overheats. Similarly, this explains the propensity of capsaicin (a TRPV1 agonist) to cause sweating (i.e.: a signal to reduce body temperature). In a recent report, it was found that tonically active TRPV1 channels are present in the viscera and keep an ongoing suppressive effect on body temperature.[13] Recently, it was proposed that predominant function of TRPV1 is body temperature maintenance [14]Experiments have shown that TRPV1 blockade increases body temperature in multiple species, including rodents and humans, suggesting that TRPV1 is involved in body temperature maintenance.[12] Recently, AMG 517, a highly selective TRPV1 antagonist was dropped out of clinical trials due to the undesirable level of hyperthermia.[15]

soooo—local anesthetics (bupivacaine) in epidural will block this receptor and will cause fever. So cool.And lidocaine on injection will stimulate this receptor and will cause burning.

couple of articles :Lidocaine and TRPV1

2 plus 2 equal 4 —-Lidocaine burning and hypertermia during labor epidural—same cause

there  a couple of articles on this topic:

The vanilloid receptor TRPV1 is activated and sensitized by local anesthetics in rodent sensory neurons

Andreas Leffler1, Michael J. Fischer2, Dietlinde Rehner1, Stephanie Kienel1, Katrin Kistner2, Susanne K. Sauer2, Narender R. Gavva3, Peter W. Reeh2 and Carla Nau1

1Department of Anesthesiology and
2Department of Physiology and Pathophysiology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany.
3Department of Neuroscience, Amgen Inc., Thousand Oaks, California, USA.

Address correspondence to

Coapplication of lidocaine and the permanently charged sodium channel blocker QX-314 produces a long-lasting nociceptive blockade in rodents.

Binshtok AM, Gerner P, Oh SB, Puopolo M, Suzuki S, Roberson DP, Herbert T, Wang CF, Kim D, Chung G, Mitani AA, Wang GK, Bean BP, Woolf CJ.


Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, Charlestown, Massachusetts 02129, USA.

Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004457.


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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



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.


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.



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








































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.


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?



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.



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]


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.


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.


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.


Centre for Perinatal Health Services Research, Building DO2, University of Sydney, Sydney, 2006, New South Wales, Australia.

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.


Mercy Hospital for Women, 163 Studley Road, Heidelberg, Melbourne, Victoria, Australia, 3084.

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.


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

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Pain free labor. “GET IT!!!!”

We need objective sign to compare different techniques of pain relief .Subjective always will be subjective. Ideal test –it is the same patient going thru exactly the same procedure twice with different methods of pain relief. So we can compare them.

This lovely lady had previous labor with regular epidural.This time she had CSE with hyperbaric tetracaine (“sacral component ” in  my sofisticated questioning). She was on her cell phone(!)  talking to her friends during pushing.What does it mean? She was very comfortable. SHE HAD NO PAIN.

Case #1 :

—Talk on your I-phone and have your baby

Case #2:

Please  this lady complains that there was NO pain—she wanted some(!)

as opposed to these: (these women could NOT talk on the cellphone during labor)

Woman giving birth




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Its NOT a rocket science

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My nurses do NOT have to work

This is about post c-section pain relief. What objective sign do we have to know difference between PO opioids (that suck) and epidural Duramorh?We can ask a nurse, because they take care of patients. How do we know that  pain  medication works? Patients do not complain, take care of themselves , less work for nurses.

My nurses do not have to work…

“to have better life, less pain” -thats what Vicki says:

(video removed temporarily)


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Psychological changes during the pregnancy—”cake or death”

Most anesthesiologists do not like to work in OB.    Why? because (besides law suites) its like working in mental institution…..there is safe , reliable , gentle technique (CSE) to make labor absolutely pain free , but they want “NATURAL LABOR!”—with insane pain , humiliation, unbearable suffering.


their decision making process something like this(please watch carefuly)

if you substitute cake for pain free labor with CSE, death for “NATURAL LABOR!”(and me for Eddie Izard) , you ll get the picture.

when woman gets pregnant she changes significantly, you can not ignore this change(insert here “Kill Bill 2″ when Uma Turman  gets pregnant :”i am the deadliest woman in the world , but now i am just shi….st  scared for my baby”)

pregnant woman becomes afraid, distrustful, ready to die for her baby.

Another problem is DENIAL—woman knows size of her vagina and size of  real baby—it does not make sense to her. Prospect of tearing herself in pieces during pushing  with her own baby? not good.

Typically women goes to complete DENIAL—”i am going deliver naturally!”(really?)(what about 30-50% c-section rate?)

When ,on hospital visit(they never come…) i explain to primigravida what to expect she should start crying.

Nobody plans labor pain-wise, pregnant women do not come for pre-labor visits to talk to anesthesiologist. Pregnant woman will go on internet to prove herself that she does not need epidural.Pregnant woman is afraid to look at her problems(coming labor), because she is afraid that there is  no solution.

Results: woman is afraid of anesthesiologist more than labor, she waits till pain is intolerable,unnecessary suffering .

Because of psychological changes  pregnant woman can not make prudent informed  decision  what she wants for pain relief for labor—-she does not listen to anesthesiologist. These changes are usually not addressed.

CAKE OR DEATH—-they usually do not choose “CAKE”(pain free labor thats available with CSE and hyperbaric tetracaine), they usually choose “NATURAL LABOR!” . Pain is natural,death is natural. Pain free labor is not natural.


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no pain after c-section for all time in hospital. How we do it?

We leave epidural catheter for 3 days  and give Morphine 2mg twice a day (or Dilaudid 0,5mg twice a day) thru epidural catheter.

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labor could be COMPLETELY pain free. How we do it?

Combined Spinal Epidural Anesthesia with hyperbaric Tetracain

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