1. Newer Analgesia Techniques CSE Julian F. Martinez-Tica, M.D.
Department of Anesthesiology

2. INTRODUCTION Labor results in severe pain for most women.
The ideal labor analgesia technique should:
Considerably reduce the pain of labor.
Allow the parturient to actively participate in the birthing experience.
Have minimal effect on the fetus or the progress of labor.
New labor analgesia techniques approach this goal.
The lecture will include mainly combined spinal-epidural analgesia (CSE), spinal opioids, patient controlled epidural analgesia (PCEA), and continuous spinal analgesia (CSA).

3. INTRODUCTION Regional anesthesia has a well-established role in labor.
The technique of combined spinal-epidural CSE analgesia has been described in labor.
The main advantage of this method is the speed of onset and completeness of analgesia.
The CSE gives rapid, reliable analgesia without motor block, and allows women walk about.
We discuss about the history, clinical experience, advantages and disadvantages of the CSE technique.

4. Table 1 Historical Development of CSE Technique
Author
Year
Surgery Indication
Single Segment
Same needle
Soresi
1937
Gen. surgery
Needle-Thru-Ndl .(N-T-N)
Coates, Mumtaz
1982
Orthopedic surg.
N-T-N
Carrie&O’Sullivan
1984
Cesarean section
Abouleish et al
1991
Labor analgesia
Ndl-Beside-Ndl double barrel
Eldor
1988
Lower body surg.
Epid and Intrathec. catheters
Vercauteren et al
1993
High-risk patients
Ndl-Beside-Cath
Van Dijk et al
1994
Lower body surg.
Double Segment
Sacral block followed by SAB
Rodzinski
1923
Epidural Block followed by SAB
Curelaru
1979
Gen. Surgery

13. by Julian Martinez Tica
Photo Album
by Julian Martinez Tica
Figure 7. A-C Various possibilities for CSE block failure owing to incorrect technique.
A, Length of spinal needle protruding from the tip of the epidural needle is too short.
B, Tip of spinal needle “tents” the dura but fails to pierce it.
C, Malposition of epidural needle.
D, Correct position of epidural and spinal needles.

14. Table 2 Suggested Drug Doses and Mixture for the CSE Technique in Labor
Administration
Local Anesthetic
Opioid
Intrathecal
Injection
Bup. 0.1%-0.25% mg
Fen ug or
Suf ug
Epidural
Top-ups
Bup %, mg for 1st stage labor. During 2nd stage of labor or for assisted delivery (e.g. forceps)
Fen ug or Suf ug

15. Advantages of the Combined Spinal-Epidural Technique
The rapid onset and completeness of analgesia during labor.
Reliable analgesia without motor block and allows women walk about.
Initial epidural needle placement allows the spinal needle to be guided near the dura.
The CSE results in lower maternal, fetal, and neonatal blood concentration of local anesthetic than with epidural anesthesia alone.
CSE analgesia is associated with more rapid cervical dilation compared with epidural analgesia alone.

16. Advantages of the Combined Spinal-Epidural Technique
6. The CSE is less likely to result in inadequate anesthesia than either technique alone.
7. With the CSE technique the initial analgesia provided by the intrathecal injection can assist in placing or replacing an unreliable epidural catheter.
8. CSE block may decrease the risk of PDPH
9. Unintended dural puncture with the epidural needle is more likely than with CSE block.

18. Ambulation With Low-Dose CSE Requires
No postural hypotension or symptoms
Minimal or no motor block
Minimal or no proprioceptive block
A cooperative, understanding parturient
Monitoring facilities, including the fetus
Presenting part of fetus engaged and well applied to cervix

19. Ambulation with low-dose CSE requires the following precautions
Avoid postural hypotension
Monitor motor block
Avoid aortocaval compression and Valsalva straining
Avoid epidural catheter displacement; ensure good fixation of catheter to skin
Provide a suitable environment, for example, shoes, safe floors, no cables, and the alike.
Simplify IV therapy by use of a hep-lock IV cannula or have the parturient ambulate with an IV pole on wheels.

21. Possible Disadvantages of the CSE Technique
Catheter migration through the dural hole
-Subarachnoid
-Intravenous
Drug Leakage
-Into the subarachniod space
-Change in epidural pressure
3. Risk of Meningitis
4. Inability to test epidural catheter
5. Contamination of CSF

22. Possible Complications and Side Effects of Intrathecal Opioids for Labor
1.- Pruritus
2.- Nausea / Vomiting
3.- Hypotension
4.- Urinary retention
5.- Uterine hyperstimulation and fetal bradycardia
6.- Maternal Respiratory Depression

24. Cerebrospinal Fluid (CSF) Flow Through Different Spinal Needles
Needle Type Needle Length Time to First CSF Drop in And Size (G) (mm) Needle Hub (sec)
Sprotte 22 (Quincke) 90 (120) <1 (20)
Sprotte
Sprotte (120) (160)
B-D Whitacre (Spinocan)
Sitting Position (20.7)
Lateral Position (46.8)

25. Incidence of Postdural Puncture Headache (PDPH) Following Combined Spinal-Epidural Block
Surg/Proc No. Patients PDPH(%) Sp. Ndl/Type Reference
C-Section Dennison
C-Section > G Brownridge
C-Section G Q Kumar
L&D G Abouleish
L&D G GM Birnbach
L&D G W Cox
Obstetric W Newman

26. Table 3 Suggested Drug Doses and Mixtures for CSE Anesthesia
PROCEDURE
ADMINISTRATION
LOCAL ANESTHETIC
OPIOID
NOTES
Standard
CSE for C
-Section
Intrathecal Injection
Bup 0.5%-0.75% mg
Fen ug
Suf ug
Epi 2-5 ug
May be ad
Epidural
Top-up
Bup %
10-40 mg
Suf ug
Sequential
Bup 0.5% mg
Suf ug
10-50 mg

28. Newer Labor Analgesia Techniques
Continuous infusion of dilute local anesthetic plus opioid
- A common infusion for labor analgesia is:
0.0625% bupivacaine with 2-4 mcg/ml fentanyl, with or without epinephrine, infusing at ml/hour.
These infusions have provided better pain relief while producing less motor block.
Maternal and neonatal drug concentrations have been demonstrated to be safe for both mother and neonate.

29. Newer Labor Analgesia Techniques
Patient controlled epidural analgesia (PCEA)
Continuous basal infusion in addition to patient controlled boluses.
Provides for a more even block and greater patient satisfaction.
Self-administration or self control and maintenance of self- esteem may be vital to a positive experience in childbirth.
Reasonable hourly limits are prescribed, and periodic assessments have to be made by an anesthesiologists.

30. Newer Labor Analgesia Techniques
Continuous spinal analgesia with microcatheters
-Due to an association with cauda equina syndrome, spinal microcatheters have been restricted by the FDA.
-An ongoing multi-institutional study is being undertaken with FDA approval (safety and efficacy of delivering sufentanil and /or bupivacaine into the intrathecal space via a 28g catheter
- To date it appears that continuous spinal analgesia for labor using a 28g microcatheter is safe and may offer several advantages.

31. Continuous spinal analgesia with microcatheters
For very high-risk parturients, many anesthesiologists are using spinal “macrocathetes”(standard epidural catheters placed in the spinal space following an intentional wet tap)
This technique has a high incidence of spinal headache or Post Dural Puncture Headache (PDPH).
It gives the greatest control in providing neuraxial analgesia and anesthesia.

32. Summary
1.- CSE is a technique of neuraxial blockade that provides greater flexibility and reliability than either spinal or epidural alone.
2.- Single-space, needle-through-needle CSE technique is quickly becoming the most popular method of neuraxial analgesia for labor worldwide
3.- Selective neural blockade is readily achieved with CSE and produces a pain-free parturient who can ambulate.

33. Summary
4.- The CSE technique could be used in early labor (< 4cm), advanced labor (> 8cm), and second stage of labor.
5.- Small doses of lipid-soluble intrathecal opioids provide excellent analgesia for the first stage of labor. The addition of mg of bupivacaine to the opioid improve the quality of analgesia for the second stage of labor.

34. References
1.- Niesen AD, Jacob AK. Combined spinal –epidural versus epidural analgesia for labor and delivery Clinics in perinatology, Elsevier 2.- Jung H, Kwak K-H. Neuraxial analgesia: a review of its effects on the outcome and duration of labor. Korean J Anesthesiol. 2013; 65(5): Eltzschig HK, Lieberman ES, CammanWR. Regional anesthesia and analgesia for labor and delivery. New Eng J Med. 2003; 348: Comparative Obstetric Mobile Epidural Trial (COMET) Study Group. Randomized controlled trial comparing traditional with two mobile epidural techniques. Anesthesiology, 2002; 97: Rawal N, Van Zunder A, Holmstrom B, Crowhurst JA. Combined spinal-epidural technique. Regional Anesthesia. 1997; 22: Norris MC, Grieco WM, Borkowsky M, et al. Complications of labor analgesia: epidural versus combined spinal-epidural techniques, Anesth Analg 1994; 79: Nielsen PE, Erickson R, Abouleish EI, et al. Fetal heart rate changes after intrathecal sufentanil or epidural bupivacaine for labor analgesia: Incidence and clinical significance. Anesth Analg 1996; 83: Campbell DC, Camman WR, Datta S. The addition of bupivacaine to intrathecal sufentanil for labor analgesia. Anesth Analg 1995; 81:

35. References
9.- Clarke VT, Smiley RM, Finster M. Uterine hyperactivity after intrathecal injection of fentanyl for analgesia during labor: A cause of fetal bradycardia? Anesthesiology 1994; 81: holmstrom B, Rawal N, Axelsson K, Nydahl P. Risk of catheter migration during combined spinal-epidural block: Percutaneous epiduroscopy study. Anesth Analg 1995; 80: Hays RL, Palmer CM. Respiratory depression after intrathecal sufentanil during labor. Anesthesiology 1994; 81: Bader AM, Fragneto R, Terui K, et al. Maternal and neonatal fentanyl and bupivacaine concentrations after epidural infusion during labor. Anesth Analg 1995;81: Paech MJ. Patient-controlled epidural analgesia in obstetrics. Int J Obstet Anesthesia 1996; 5: Arkoosh VA, et al. Continuous spinal labor analgesia using a 28 gauge versus continuous epidural labor analgesia. Anesthesiology 2008;1087: