- Initial analgesia provided by intrathecal administration of an analgesic (or mixture)
- Labor analgesia is maintained using analgesic(s) delivered via an epidural catheter
See Chapters 121, 122, 123, and 124 for Figures.
- Epidural space accessed using an epidural needle
- A long spinal needle is passed through the epidural needle into the intrathecal compartment
- The spinal analgesic is administered and the spinal needle is withdrawn:
- Most common intrathecal doses are: 2–2.5 mg isobaric 0.25% bupivacaine or 0.2% ropivacaine with 10–20 μg fentanyl or 2–2.5 mg sufentanil
- An epidural catheter is passed via the epidural needle, aspirated, and secured as usual
- An epidural infusion is started as usual:
- Testing of the epidural catheter is not common:
- Careful aspiration for blood and CSF usually reveals intravascular or intrathecal catheter placement in multiorifice catheters
- Spinal effects are hard to differentiate from the original spinal dose
- Intravascular catheter placement testing with diluted epinephrine is notoriously poor in obstetrical patients:
- Heart rate variability at baseline is considerable due to periods of pain
- There is no EKG monitoring to assess T-wave amplitude
- Response to epidural infusion often reveals concealed intrathecal or inadvertent intravascular catheter position:
- Currently used dilute concentrations of epidural infusions are unlikely to produce rapid, dangerous cephalad spread of neuraxial blockade
- Do not bolus an “untested” catheter with a full bolus dose immediately after a CSE dose (i.e., without an infusion running for 15–20 minutes) without testing for intrathecal and intravascular placement first as it may produce inadvertent high blocks or local anesthetic toxicity
- Starting an epidural infusion straightaway allows onset of epidural analgesia by the time the spinal dose wears off
- Adjust inadequate level of initial analgesia by bolusing the epidural catheter:
- Initial doses may need to be reduced by about half
- After about 30–45 minutes, usual “top-up” boluses should have the same effect as with a routine labor epidural
Comparison with Epidural Analgesia for Labor Pain
|Combined spinal epidural||Epidural|
|Rapid onset||Slower onset|
|Good or excellent initial analgesia in most cases||Initial analgesia good or satisfactory in most cases|
|Overall satisfaction with labor analgesia is the same|
|Good option in late first stage of labor||Sacral spread is poor; may not provide analgesia in patients presenting in advanced labor|
|Clear end point on insertion (CSF)||Placement is determined on subjective “feel”|
|Fewer failed epidural catheters in less experienced hands|
|Postdural puncture headache incidence is ˜0.5–1%||Postdural puncture headache incidence is ˜1%|
|There have been recent reports of meningitis cases in healthy pregnant women||Meningitis in healthy pregnant women is exceedingly rare (no large-volume study has included cases of healthy pregnant women until now)|
|Maintenance of a sterile technique with cap/mask on everyone present in the room is important|
|Fetal bradycardia incidence increases with dose of intrathecal narcotic (use ≤20 μg fentanyl or ≤2.5 μg sufentanil)||Fetal bradycardia with epidural narcotics has been observed|
|Rapid onset of sympathectomy; increased ...|
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