"Our data suggest that CSE is as safe as epidural anesthesia for pain relief in laboring patients," Birnbach concluded. "There were no complications in either group."
Birnbach, D.J., et al. "Complications of Combined Spinal Epidural
(CSE) Analgesia Compared with Lumbar Epidural Analgesia,"
Anesthesiology, September 1996, 85 (3A), A-860
COMBINED SPINAL EPIDURAL TAKES THE LABOR OUT OF CHILDBIRTH
Childbirth does not have to be a painful experience says anesthesiologist Dr. Michael Newman. Using a combined spinal epidural, or walking epidural, obstetric anesthesiologists at Rush have helped almost 5,000 women go through regular labor comfortably. "There's absolutely no good reason for a woman to have to suffer through childbirth," he says. When using a combined spinal epidural, an anesthesiologist injects a small amount of potent opiate into the cerebro spinal fluid,
which is located in an area below the spinal cord. He then puts a catheter in the epidural space and gives the patient a diluted solution of opiate and local anesthetic. The medication may be given to a patient when she first comes to the hospital in pain and is given continuously through delivery. The advantages of having a combined spinal epidural are that it not only provides pain relief, but also enables the patient to move her legs. The patient can move around in bed, walk around, sit in a chair or go to the bathroom rather than having to use a bed pan. Walking epidurals do not adversely affect
either the mother or the baby. Patients may experience itching and a few patients, 1 in 100, may get a spinal headache--both of which are temporary and easily treated. The pain most women have during labor is easily managed with a walking epidural. Only the small group of women who have back labor, which is caused by the position of the baby's head, does not benefit as much from the combined spinal epidural as their counterparts.
'WALKING' EPIDURALS LEAVE MOTHERS MOBILE DURING LABOR
Blocking labor pain by injecting anesthetic into the epidural space of the spine is not a new technique: It's been used with great success for 20 years. However, while it does relieve a mother's pain during childbirth, its drawback is that it numbs her legs, leaving her stranded in bed.
"Walking" epidurals being given at Rush-Presbyterian-St. Luke's Medical Center block pain receptors without deadening nerves, allowing the mother to get up, walk around or visit the restroom. Mothers with walking epidurals are able to regulate their own dosage, giving themselves more of the pain-relieving medication as they feel the need. Walking epidurals
carry minimal risk to both mother and child and cost the same as a standard epidural. Some practitioners believe that walking during labor aids delivery, allowing gravity to do some of the work.
One physician administering the walking epidural at Rush is anesthesiologist Dr. L. Michael Newman. "Patients who have had both standard and walking epidurals absolutely love walking epidurals," Newman said. "It leaves a woman in control."
"It's like night and day," first-time mother and Rush patient Jodie Voss said, free of pain and able to move about after she was given a walking epidural. "I don't think anybody likes being stranded in bed. To get up and walk around is wonderful."
MEDLINE Search Information
Title The use of intrapartum intrathecal narcotic analgesia in a community-based hospital.
Herpolsheimer A; Schretenthaler J
Obstetrics and Gynecology Service, 95th Combat Support Hospital, Heidelberg, Germany.
Obstet Gynecol, 84: 6, 1994 Dec, 931-6
OBJECTIVE: To evaluate the use of intrapartum intrathecal narcotic analgesia in the obstetric population of our community-based hospital. METHODS: A protocol to administer intrapartum intrathecal narcotic analgesia was established at our institution in December 1992. All patients consenting to this procedure received a single lumbar intrathecal injection of 25 micrograms fentanyl and 0.25 mg morphine sulfate through a 25-gauge spinal needle. Only those patients with singleton pregnancies in the vertex presentation were included in this study. The study group was matched by gravidity and parity with singleton pregnancies delivered during the study period. Patients in the study group were asked to complete an analgesia satisfaction survey using a five-point Likert scale ranging from 0 for total dissatisfaction to 5 for total satisfaction. RESULTS: A total of 75 patients were assigned to each group; the control and study groups were similar with respect to age, race, estimated gestational age, infant
birth weight, interval between rupture of membranes and delivery, and mode of delivery. The length of the first and second stages of labor and the incidence of fetal malposition were not significantly different between the two groups. Frequent side effects of this analgesia included complaints of pruritus (81.3%), urinary retention (53.3%), and nausea and vomiting (44.0%). Headaches were less common (9.3%), with two (2.7%) of seven patients requiring an epidural blood patch for relief. Infrequent side effects included respiratory depression (1.3%) and oversedation (1.3%). Patients were generally satisfied with the degree of pain relief obtained, rating it highly during the first and second stages of labor and in comparison to their previous labor experience. CONCLUSION: The use of intrapartum intrathecal narcotic analgesia provides a satisfactory level of pain relief without disrupting the normal course of labor.
TitleComfortable labor with intrathecal narcotics.
Zapp J; Thorne T
Anesthesia Service, Reynolds Army Community Hospital, Fort Sill, OK 73503, USA.
Mil Med, 160: 5, 1995 May, 217-9
Aggressive pursuit of high-quality health care had guided the Health Service of the United States Army to establish a labor analgesia program within its hospitals. A dedicated Labor Epidural Service can be quite expensive, especially from the manpower standpoint. Therefore, the Anesthesia Service at Reynolds Army Community Hospital, Fort Sill, Oklahoma, implemented a program of intrathecal narcotic injection as an alternative to costly labor epidural analgesia. After reviewing a patient fact sheet, 150 laboring patients volunteered for labor intrathecal analgesia (LIA). Once active labor began, the patient received intrathecal morphine (0.25 mg) and fentanyl (25 micrograms).
The pain level before and after the LIA was evaluated by the visual analog schedule method. At 2 weeks follow-up the intrathecal narcotic-assisted labor was subjectively reported by the patients. Ninety-four percent of the patients agreed that the LIA worked well and that they would do it again. LIA was found to be a well-accepted, cost-saving, very effective approach to labor analgesia.
TitleIntrathecal narcotics for labor using combined spinal epidural technique: an attractive option for solo anesthesia
Keller RJ; Elliott C
CRNA, 6: 3, 1995 Aug, 125-8
A 31-year-old primigravida woman presenting with term pregnancy was admitted for labor and delivery. After approximately 10 hours of labor, which included an oxytocin infusion, she requested anesthesia intervention. A combined spinal/epidural (CSE) block was administered featuring a 3 1/2-in, 18-gauge Hustead epidural needle into the epidural space, through which was placed a 4 11/16-in, 27-gauge Whitacre spinal needle into the subarachnoid space. Fifty micrograms of fentanyl, 0.25 mg of morphine, 0.2 mg of epinephrine, and 2 mL of perservative-free normal saline were given intrathecally, the spinal needle was withdrawn, and a catheter placed into the epidural
space. Profound analgesia without motor impairment was achieved. After the patient failed to progress, 2% lidocaine was administered epidurally to provide anesthesia to a T4 level, and a cesarean section was performed.
The CSE technique provides a safe, flexible choice of anesthesia for labor and delivery. Monitoring of the patient by the anesthetist is necessary for only the initial 30 minutes after block administration. This, coupled with the advantage of having an epidural catheter as a backup, makes it an especially attractive alternative for the solo anesthetist.
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