EPIDURAL ANALGESIA Epidural analgesia is an injection of local anaesthetic alone, or more commonly in combination with pain.

The injection is usually made in the lumber region at the L2/3 or L3/4 space. Epidural analgesia provides a reliable and excellent analgesia during childbirth without resulting in concomitant maternal or foetal central depression seen with systemic opioids. In most centres, a combination of local anaesthetic and opioid is administered via the epidural catheter. This method improves pain control, uses a smaller dose of either drug, and therefore has fewer side effects. Epidural analgesia provides complete motor (causing paralysis) and sensory blockade (causing loss of sensation), around or near the site of pain. The level of epidural block usually extends distal from the upper abdomen. As a consequence of epidural analgesia; women become immobile and require more frequent observations by a midwife.

TYPES OF ANALGESIA USED IN EPIDURAL ANALGESIA

There are different types of analgesia used in epidural analgesia, for instant the local anaesthetics and or opioids. 1. Epidural Local Anaesthetics Some examples of local anaesthetics include bupivacaine hydrochloride, ropivacaine hydrochloride and lignocaine hydrochloride. Bupivacaine hydrochloride: Bupivacaine is a local anaesthetic that stabilises the neuronal membrane and prevents the initiation and transmission of nerve impulses. This drug is very potent, four times that of lignocaine, and has a rapid onset of anaesthesia with prolonged duration of action. Bupivacaine is suitable for continuous epidural blockade. Ropivacaine hydrochloride: This drug also behaves in the same manner as bupivacaine with exception that ropivacaine has both anaesthetic and analgesic effects. At higher doses it produces surgical anaesthesia with motor block, while at lower doses it produces a sensory block, including analgesia, with little motor block.

Lignocaine hydrochloride: This medicine has the same mechanism of anaesthetic action to that of bupivacaine and ropivacaine.

2. Epidural opioids The lipid solubility of opioids influences its onset and duration of action. Lipophilic (fat soluble) opioids, such as fentanyl, are able to penetrate the dura or the arachnoid membranes and spinal tissues resulting in a rapid onset of analgesia, but a limited duration. On the other hand, hydrophilic (water soluble) drugs such as morphine have slow diffusion rate in the spinal membrane, thus slower onset of action and longer duration. Morphine: is an opioid with sedative properties used to relieve severe or constant pain such as childbirth pain, which cannot be controlled by any other pain relievers. Morphine exerts its analgesic effects by acting as an agonist and activating the opioid receptors in both the central and peripheral nervous systems; In doing so, the pain threshold is elevated and the brain's awareness of the pain is decreased. Fentanyl: The principal actions of fentanyl are analgesia and sedation. It exerts its effects by acting on specific opioid receptors in the brain, through which they block the pain messages being delivered. In doing so, fentanyl decreases the brain's awareness of the pain and provides pain relieve to the patient. Like any other analgesics, fentanyl produces respiratory depression, drowsiness, sedation and constipation.

INDICATIONS: Prolonged labour Difficult forceps delivery Maternal exhaustion during labour Pre-eclampsia Unacceptable pain during labour

CONTRAINDICATIONS: History of hypersensitivity or allergy to any previous medications including anaesthetics and opioids Local inflammation or infection Spinal deformity or previous spinal surgery Bleeding or clotting disorders

Cardiovascular disease/s such as heart failure, cardiac ischemia, hypertension or hypotension and/or any other cardiac complications Nervous system disease Neuromuscular disease such as myasthenia gravis Any other medical conditions

POSSIBLE SIDE-EFFECTS: A drop in blood pressure. A drop in the mother's blood pressure will affect how much of her blood is pumped to the placenta, and can lead to less oxygen being available to the baby. It can slow a woman's labour. The second stage of labour is particularly slowed. It will numb the bladder, and a woman may not be able to pass urine. Pruritis or generalized itching of the skin. Morphine also causes oral herpes in 15% of women. It can cause nausea and vomiting. Up to 1/3 of women with an epidural will experience shivering which is related to effects on the bodys heat-regulating system. When an epidural has been in place for more than 5 hours, a woman's body temperature may begin to rise; this will lead to an increase in her own heart rate and her baby's heart rate. LESS COMMON SIDE-EFFECTS: Accidental puncture of the dura, or spinal cord coverings which can cause a prolonged and sometimes severe headache. Ongoing numb patches Weakness and loss of sensation in the areas affected by the epidural. Permanent nerve damage Convulsions Heart and breathing difficulties Death attributable to epidural