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224: Epidural Analgesia and Mode of Delivery in Primiparous Patients Undergoing Induction of Labour
142
Posters
•
Obstetrics
218. Combined spinal epidural: choice of anaesthesia for caesarean section in achondroplasia
224. Epidural analgesia and mode of delivery in primiparous patients undergoing induction of labour
S. Samuel1, S. Ghatge1, F.J.E. Jacintha2 1University Hospital North Staffordshire, Anaesthetics, Stoke-on-Trent, UK, 2Queen’s Hospital, Department of Anaesthetics, Burton-on-Trent, UK
J. Dolan1, S. Young1, J. Kinsella2 1Glasgow Royal Infirmary, Anaesthetic Department, Glasgow, UK, 2University of Glasgow, Anaesthetic Department, Glasgow, UK
Introduction: We present the anaesthetic management of an achondroplastic parturient for a Caesarean section using a Combined Spinal Epidural(CSE).
Background and Aims: Epidural analgesia (EDA) reduces labour pain effectively. While EDA prolongs labour, the impact on instrumental delivery (ID) and caesarean section (CS) rates is controversial1. This prospective study compared the mode of delivery in primiparous women who received or did not receive EDA after the induction of labour.
Case Report: A 37 yr old achondroplastic woman, Gravida 3 Para 2 with 2 previous Caesarean sections under General Anaesthesia presented for elective caesarean section. She was keen to be awake during the operation. She was 3ft 6” tall and weighed 55 kgs. After discussion with the patient, she had a CSE ( needle through needle) performed in the sitting position at L3/L4 interspace. The epidural space was located with loss of resistance to saline at a depth of 5 cm. In the first attempt she had severe paraesthesia while inserting the spinal needle. The procedure was repeated uneventfully in the same space. 1.4 mls of 0.5% Heavy Marcaine & 400 microgrammes (0.4 mls ) of Diamorphine was injected intrathecally. Phenylephrine infusion was used to maintain hemodynamic stability. She had a block height of T2 to cold & pinprick, & T6 to touch & was comfortable throughout the procedure, thus not requiring any top-up via the epidural catheter intra-operatively. A healthy female baby was delivered and the operation uneventful. Discussion: With their characteristic large head and mandible, atlanto-axial instability and limited neck extension, achondroplastics can be potentially difficult to intubate, making regional anaesthesia a reasonable choice. But with associated possibility of spinal stenosis and lumbar lardosis, a very high block (as in this case, upto T2 with 1.4 mls) or total spinal is a risk with spinal anaesthesia. CSE allows the use of a lower intra-thecal dose with the facility to top-up epidurally if the block heght is inadequate (although it was not required in this case), also allowing better hemodynamic stability. Thus, CSE could be the choice of anaesthesia for caesarean section in achondroplastic women.
Methods: After Local Research Ethics Committee approval, consenting primiparous patients undergoing induction of labour for post estimated delivery date were admitted to the study. None had antenatal obstetric or foetal compromise. In each patient the mode of delivery (CS; ID; Spontaneous Vertex [SVD]) was correlated with the method of pain relief during labour, either parenteral morphine (IM) alone or continuous EDA (0.1% bupivacaine with 2ug/ml fentanyl). Results: Of the 111 patients admitted to the study 77 (69.3%) received EDA while 33 (30.7%) received IM. In the EDA group the incidence of CS, ID and SVD was 38 (49.5%), 23 (29.8%) and 16 (20.7%). respectively. In the IM group the respective figures were 8 (24.2%), 6 (18%) and 19 (57.8%). The incidence of CS was significantly higher in the EDA group (p ⫽ 0.001) while the incidence of SVD was significantly higher in the IM group (p ⫽ 0.001). There was no significant difference between the EDA and IM groups in the incidence of ID (p ⫽ 0.232). Conclusions: In primiparous women undergoing induction of labour, caesarean sections are more commonly associated with those patients who have received epidural analgesia but not parenteral opiates for pain relief in labour. Instrumental delivery was unrelated to the choice of labour analgesia.
References 1. Ros A., Felberbaum R., Jahnke I., Diedrich K., Schmucker P. and Huppe M. Epidural anaesthesia for labour: Does it influence the mode of delivery? Arch Gynecol Obstet 2007; 275: 269-274.
Posters
•
Obstetrics
218. Combined spinal epidural: choice of anaesthesia for caesarean section in achondroplasia
224. Epidural analgesia and mode of delivery in primiparous patients undergoing induction of labour
S. Samuel1, S. Ghatge1, F.J.E. Jacintha2 1University Hospital North Staffordshire, Anaesthetics, Stoke-on-Trent, UK, 2Queen’s Hospital, Department of Anaesthetics, Burton-on-Trent, UK
J. Dolan1, S. Young1, J. Kinsella2 1Glasgow Royal Infirmary, Anaesthetic Department, Glasgow, UK, 2University of Glasgow, Anaesthetic Department, Glasgow, UK
Introduction: We present the anaesthetic management of an achondroplastic parturient for a Caesarean section using a Combined Spinal Epidural(CSE).
Background and Aims: Epidural analgesia (EDA) reduces labour pain effectively. While EDA prolongs labour, the impact on instrumental delivery (ID) and caesarean section (CS) rates is controversial1. This prospective study compared the mode of delivery in primiparous women who received or did not receive EDA after the induction of labour.
Case Report: A 37 yr old achondroplastic woman, Gravida 3 Para 2 with 2 previous Caesarean sections under General Anaesthesia presented for elective caesarean section. She was keen to be awake during the operation. She was 3ft 6” tall and weighed 55 kgs. After discussion with the patient, she had a CSE ( needle through needle) performed in the sitting position at L3/L4 interspace. The epidural space was located with loss of resistance to saline at a depth of 5 cm. In the first attempt she had severe paraesthesia while inserting the spinal needle. The procedure was repeated uneventfully in the same space. 1.4 mls of 0.5% Heavy Marcaine & 400 microgrammes (0.4 mls ) of Diamorphine was injected intrathecally. Phenylephrine infusion was used to maintain hemodynamic stability. She had a block height of T2 to cold & pinprick, & T6 to touch & was comfortable throughout the procedure, thus not requiring any top-up via the epidural catheter intra-operatively. A healthy female baby was delivered and the operation uneventful. Discussion: With their characteristic large head and mandible, atlanto-axial instability and limited neck extension, achondroplastics can be potentially difficult to intubate, making regional anaesthesia a reasonable choice. But with associated possibility of spinal stenosis and lumbar lardosis, a very high block (as in this case, upto T2 with 1.4 mls) or total spinal is a risk with spinal anaesthesia. CSE allows the use of a lower intra-thecal dose with the facility to top-up epidurally if the block heght is inadequate (although it was not required in this case), also allowing better hemodynamic stability. Thus, CSE could be the choice of anaesthesia for caesarean section in achondroplastic women.
Methods: After Local Research Ethics Committee approval, consenting primiparous patients undergoing induction of labour for post estimated delivery date were admitted to the study. None had antenatal obstetric or foetal compromise. In each patient the mode of delivery (CS; ID; Spontaneous Vertex [SVD]) was correlated with the method of pain relief during labour, either parenteral morphine (IM) alone or continuous EDA (0.1% bupivacaine with 2ug/ml fentanyl). Results: Of the 111 patients admitted to the study 77 (69.3%) received EDA while 33 (30.7%) received IM. In the EDA group the incidence of CS, ID and SVD was 38 (49.5%), 23 (29.8%) and 16 (20.7%). respectively. In the IM group the respective figures were 8 (24.2%), 6 (18%) and 19 (57.8%). The incidence of CS was significantly higher in the EDA group (p ⫽ 0.001) while the incidence of SVD was significantly higher in the IM group (p ⫽ 0.001). There was no significant difference between the EDA and IM groups in the incidence of ID (p ⫽ 0.232). Conclusions: In primiparous women undergoing induction of labour, caesarean sections are more commonly associated with those patients who have received epidural analgesia but not parenteral opiates for pain relief in labour. Instrumental delivery was unrelated to the choice of labour analgesia.
References 1. Ros A., Felberbaum R., Jahnke I., Diedrich K., Schmucker P. and Huppe M. Epidural anaesthesia for labour: Does it influence the mode of delivery? Arch Gynecol Obstet 2007; 275: 269-274.