‫بسم الله‬

‫الرحمن الرحيم‬
Epidural Analgesia
For Labour

By
Dr . K h a i r y E h a b
e s t h e s i a & I
PhD Of An
 Objectives
1- Pathway of labour pain
2- The adverse effects of pain on mother
and fetus
3- The goal & benefits of epidural
analgesia.
4- When to initiate epidural analgesia.
5- The absolute & relative
contraindications.
6- Anatomy of epidural Space.
7- Patient position during the procedure.
8- Emergency Equipment, Drugs, &
Monitoring.
PAIN TRANSMISSION &
MODULATION
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Second level
● Third level

● Fourth level

● Fifth level
Pathways & Segmental
block1st stage of
labour
Aδ & C
Visceral Afferent
fibers is referred
to the
dermatomes of
T10 to S4
2nd stage of
labour Somatic
pain from
stretching and
The adverse effects of
pain on mother and
fetus
 Obstetric Pain
Management
“Our Goal”
Best analgesia with the least
side effects.

Why Epidural Analgesia Is

Excellent?
1- It provides true segmental
pain relief.
 Benefits Of Epidural
•
Analgesia
Excellent analgesia with less
sedation.
• Walking epidural / Earlier
ambulation.
• Decreased pulmonary
complications.
• Decreased incidence of venous
thrombosis.
• Earlier return of bowel function
…….. !
 Best Time for Insertion
& initiation Of Epidural
Analgesia
1- Regular effective contractions (3/10
min).
2- When the cervixes is dilated (2-3 Cm).
3- When the head is engaged.

That’s To Say
 ABSOLUTE
CONTRAINDICATIONS
1-Patient's refusal &/Or uncooperative.
2- True allergies to local anesthetics.
3- Anticoagulation therapy.
4- Coagulopathies, & Thrombocytopenia.
5- Marked hypovolemia & certain heart
diseases.
6- Decreased level of consciousness.
7- Infection over the injection site.
8- Increased intracranial pressure.
 RELATIVE
CONTRAINDICATIONS
1- Preexisting neurological disease.

2- Back disorders.

3- Some forms of heart diseases.

4- Systemic infection.

5- Lack of qualified nursing care to

monitor patients for side effects and
complications.
 THE EPIDURAL SPACE
• A ‘potential space’ contains fat and
blood vessels
• Located ; between the bony vertebral
canal and the outer surface of the Dura
mater.

• Moving towards the spinal cord from

the epidural space are 3 meninges that
cover the spinal cord.
1) Dura mater.
2) Arachnoid mater.
3) Pia mater.
Spinal Anatomy
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Epidural Needle
Level Of Epidural
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Placement Of Epidural
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 Patient Sitting Position
Patients must be held
1- Stable, straight

Positions alignment
2- Flexing = Arching
their back by hugging a
pillow…….. Why?

1- Easier to Identify the anatomic

midline.
2- Widen the passage for Epidural
 Arch Pt. Back “Like A Mad cat" OR,
THE Anesthetist Becomes Mad

1- Brings the spine closer to the skin surface.

2- Maximizes the area between adjacent spinous processes.
Lateral Decubitus
Patients lie on
their side with their
knees flexed and
pulled high against
the abdomen or
chest, assuming a
“fetal
position”
An
Equipment

Drugs

Monitoring
 Equipment Before
Regional Block
1- Oxygen.
2- Suction.
3- functioning laryngoscopes.
4- Oral or Nasal airways.
5- Endo- tracheal tubes (6 or 6.5
mm).
6- A bag mask device for positive-
pressure ventilation.
 Drugs That Should Be
Available Before Regional
1- Intravenous Block
fluids.

2- Ephedrine.

3- Atropine.

4- Thiopental or Propofol.

5- Succinylcholine.
 Monitoring Should Be
Available During
Regional Block
1- Blood pressure.

2- Heart rate.

3- A pulse oximeter.

4- Capnograph.
 Epidural
Analgesics
 Opioid Based Epidural
Agent Analgesia
Epidural Onset
Duration

Morphine 5–7.5 mg 30–60 min

12–24 h

Meperidine 50–100 mg 10–30 min

1–3 h

Fentanyl 50–150 μg 5–10 min

1–2 h
 Side Effects Of Epidural
Opioid
1- A- Early Analgesia
respiratory
depression.
B- Delayed-onset respiratory
depression.
The risk of respiratory depression
is greatly
increased if systemic opioids (IV,
IM, or PO) are
co administered with epidural
opioids.
2- Nausea and vomiting.
 Epidural Local
Anesthetics
Bupivacaine 0.25% OR
Ropivacaine 0.2%
Although it can be used
alone, there is rarely a reason
to do so ………… Why?
Higher concentration of
local anesthetic is required
resulting into more side
effects
 Systemic Toxicity
Of
I- Central L.A. System
Nervous
A- Initial symptoms:
lightheadedness,
Dizziness, Metallic taste,
Circum-oral numbness, &
Ringing in the ears.
B- Excitatory phase:
Shivering, Muscle
 II-Cardiovascular systemic
toxicity
Initially Manifisted by:
Hypotension &/OR Bradycardia

“ May be, transient,

But. . . . . . . . .
May ,
Progress into:
Profound hypotension,
Myocardial depression &
 Combination Of Opioids
& Local Anesthetic
Advantages:
1- Synergism between the 2
drugs due to separate sites of
action Better
Analgesia.
2- Allows the use very low
concentrations of both local
anesthetic and opioid
Minimize adverse side effects.
 NURSING ASSESSMENT,
DOCUMENTATION, AND MANAGEMENT
OF
SIDE EFFECTS AND COMPLICATIONS
 GENERAL PATIENT
MANAGEMENT
1- Maintain 18 G IV access while
inserting, receiving epidural analgesia
and, for 8 hours following the last
administration of medication.
2- Medications should be sterile,
preservative-free.
3- Do not use Alcohol “neurotoxic”.
4- No concomitant administration of
Opioids. without notifying the APS.
5- No Anticoagulation therapy should
be initiated or changed before notifying
the APS.
 ASSESSMENT OF
1- Analgesia & Motor Levels
Every 4 hours while awake,
both at rest and with activity,
using VAS (1- 10).
• Documentation: On Pain

Management flow sheet

• Management: If analgesia
is inadequate
# Increase
the rate of infusion.
2- SIDE EFFECTS
1-Increased Sedation /
Respiratory Depression
• Assessment: Every hour for the

first 24 hours
• Documentation: On Pain

Management flow sheet

• Warning: Do not administer

systemic opioids or CNS

depressants without notifying the
APS
 Sedation Score
• 1 = Anxious, agitated, or restless.
• 2 = Calm, cooperative to tranquil =
normal patient’s baseline without
sedation.
• 3 = Quiet, drowsy, responds to verbal
commands.
• 4 = Asleep, brisk response to forehead
tap or loud verbal stimuli.
• 5 = Asleep, sluggish response to
increasingly vigorous stimuli.
• 6 = Unresponsive to painful stimuli.
 Management
Sedation Score > 5 Or
• 1. Stop the epidural infusion.
•
RR < 8
2. Naloxone if ordered on
Physician orders.
• 3. Notify the APS.
• 4. Administer oxygen, check
the patient’s oxygen
saturation level.

•
 Manage & Notify
# Nausea & Vomiting: Primpran 10 mg IV.
APS
# Pruritus: Nalbuphine Or Diphenhydramine.
# Urinary retention: Foley catheter.
# Bradycardia < 60/ min: Atropine 0.5 mg IV.
# Systolic Hypotension < 90 mmHg:
1- Ensure adequate hydration
2- Lt Lat. Position
3- Ephidrine 5 mg IV PRN
4- O2 Administration
COMPLICATIONS OF EPIDURAL
ANALGESIA
Epidural abscess
Assessment:
Every 4 hours for
changes in sensory/motor
function including unexplained
back pain, bowel or bladder
dysfunction, fever, or neck
stiffness.
Every 8 hours for
 Epidural Hematoma
Assessment:
Every 4 hours for
Changes in sensory/motor
function including progressive
numbness, weakness, or
bowel and bladder
dysfunction.
Every 8 hours for
 Epidural Catheter
AlwaysMigration
Aspirate Before
inject
I- Subdural puncture
Causing an overdose of
opioid and local anesthetic

Assessment: Sudden or
progressive increase in side
II- Catheter Migration Into
An Epidural Vessels
So that drugs are delivered systemically
Assessment: # Blood
in the tubing.
#
Inadequate analgesia.
# Local
anesthetic toxicity.
#
 Disconnection of the
epidural catheter from
# Cover the ends with sterile gauze.
the filter
# Notify the APS immediately.

Cracked catheter or filter

Assessment: Clear fluid
may accumulate under
dressing.
Management: Notify the
APS immediately.
 Maternal Fever
# Commonly in nulliparous women, who
often have prolonged labor and are more
likely to receive epidural analgesia.
# It may be interpreted as
chorioamnionitis and triggers an invasive
neonatal sepsis evaluation.
“Yet epidural analgesia has no
relation
to those kind of sepsis”
# The Epidural Role
1- Epidural-induced shivering
2- Inhibition of sweating
 Post Epidural
1- Without dural puncture
A self-limited headache may
Headache
occur; only when a large
amounts of air is injected into
the epidural space during a loss
of resistance technique.

2- Postdural Puncture
Headache (PDPH)
 Treatment Of
Mild headache
PDPH
1. Bed rest, & hydration
2. Oral analgesics
3. Epidural saline injection (50 mL)
4. Caffeine sodium benzoate (500
mg IV)
 Moderate to
May require an epidural blood patch
severe
(15–20 mL). headaches
Yet

Prophylactic epidural
blood patches are generally
not recommended; As
 Before Removal of
1- BeEpidural Catheter
sure that pt. is not on
Anticoagulants
# 12 hrs. from the last L.M.W.H
prophylactic dose.
# 6 hrs. from the last Heparin dose.
2- Use a septic technique.
3- Inspect the site of the catheter for
development of an Abscess or
Hematoma formation.
Technique Of catheter
Removal
1- Hold the catheter close to the skin,
gently pull out the catheter 1/1 cm …
Never Use Force … ?
2- Ensure removal of the catheter
tip marked “Blue”.

3- Use An antiseptic solution

& dress the site with a sterile
Thank you