Pitfalls of an Effective Labour Epidural- A Case

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Options for labor analgesiagoing completely without

being totally pain free

Epidural analgesia the " most popularmeans for pain relief during labor.

Considered Gold standardHowever, not without

controversy

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Pt awake & able to participate Effective pain relief without appreciablemotor block

Reduction in maternal CA

Drug induced fetal depression unlikely

A means to rapidly achieve surgicalanesthesia

Pruritis

Nausea, vomiting

Respiratory depression Fetal bradycardia

Complications of the technique

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29/F

G3 P2 L2 A0 at 36wks 4d

DOA: 1st

june 2010 at 4.50pm

Risk factor: oligohydraminos

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62kg

149cm

86/min 120/80mmHg

Inv:

Hb 10.4/24.7 Platelet count 2.05lac

BT 2 05/ CT 515

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7pm:

Syntocin started

8.30pm Tab Misoprost 25mg intravaginally

11pm

Foleys catheterization

00.30am

Tab Misoprost 25mg intravaginally

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3.30am

Epidural analgesia

L2-3 interspace 8ml 0.25% sensoricaine 0.125%Sensoricaine with fentanyl 2mcg/ml @ 8ml/hr

Vitals: 86/min, 120/80mmHg, 97%

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6.30am

Vaginal delivery

2.6kg live healthy baby Placenta delivered

Episiotomy stitched in layers

Catheterization done

7.00am

Hematuria Urethral injury suspected

Patient shifted to OT

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EUA Surgical exploration epiduralanesthesia

Revealed extensive injury to

Anterior vaginal wall

Cervix

Lower uterine segment

Posterior wall of bladder Trigone

Bladder neck

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Inspite of these extensive injuries, the

patient was completely comfortablewith no complaint of pain at anytime.

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In a study by Bujold and Gauthier, abdominalpain was the first sign of rupture in only 5% ofpatients and occurred in women whodeveloped uterine rupture without epiduralanalgesia but not in women who received anepidural block.

Thus, abdominal pain is an unreliable anduncommon sign of uterine rupture.

Bujold E, Mehta SH, Bujold C, Gauthier RJ.Interdelivery interval anduterine rupture.Am J ObstetGynecol.Nov2002;187(5):1199-202

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Concerns that epidural anesthesia might mask thepain caused by uterine rupture/injury have notbeen verified and there have been no reports ofepidural anesthesia delaying the diagnosis of

uterine rupture.

A guideline from ACOG from 2004 suggeststhere is no absolute contraindication toepidural anesthesia for a trial of labour

because epidurals rarely mask the signs andsymptoms of uterine rupture.ACOG Practice Bulletin #54: vaginal birth after previouscesarean.Obstet Gynecol.Jul2004;104(1): 203-12.

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Continued vigilance and collaborationbetween obstetricians &anaesthesiologists is necessary after

every intervention, as even effective painrelief can have its drawbacks.

A high index of suspicion should therefore

always be present as epiduralanalgesia.