questions on epidural, fetal distress

[Guest guest]

The objectives of this post are several. Childbirth professionals

(both midwives and MDs) administer epidurals because mothers ask.

However, mothers should know full implications and later price to be

paid. Secondly, C-section decision is often taken on the ground of

fetal distress. But fetal distress itself can be caused by

intervention? Techniques to relieve fetal distress under such

circumstances are also getting reported. The author would like to

draw attention of prospective mothers to the summary of scientific

findings in this respect. Some of the literature supporting the

statements has been cited in earlier post by bhanutikare and extra

information of educational nature is summarised here with due credits

to original authors. Author responsible for omissions and mistakes if

any, but he requests Dr Mankikar to broaden our understanding further.

 

Epidural anasthesia has been successfully used in surgery, obstetrics

and pain control, as it permits continuous anaesthesia after

placement of an epidural catheter, making it suitable for procedures

of long duration.

 

Women going through labor, may ask for it after experiencing the pain

levels, but while in pain, they may not be in mood or mental state to

study and ponder over the risks after effects or consequences. Do

they make the decision with following full information?

 

The objective of this post is also to point out that the professional

skill of the doctor administering the anasthesia must be very high.

 

1) Epidural inhibits beta-endorphin production and therefore also

inhibits the shift in consciousness that is part of a normal labor.

When an epidural is in place, the oxytocin peak that occurs just

before birth during normal labor is inhibited and the effect may

persist after epidural has worn off. Missing of the fetal ejection

reflex forcing mother to use her own effort, often against gravity,

to compensate this loss. Increased length of the second stage of

labor and the extra need for forceps may arise when epidural is used.

 

2). The effect of epidurals inhibiting catecholamine release may be

advantageous in the first stage of labor, however, a reduction in CA

levels will further inhibit the fetal ejection reflex, which involves

catecholamines as well as oxytocin.

 

3) Adverse effect on Release of the important uterine stimulating

hormone prostaglandin F2 is also adversely affected by epidurals. The

level of this hormone rises during an undisturbed labor; however,

women with epidurals experience a decrease in PGF2 alpha and a

prolongation of labor.

 

4)Drugs administered by epidural enter the mother's bloodstream

immediately and go straight to the baby at equal, or sometimes

greater, levels. Some drugs will be preferentially taken up into the

baby's brain, and almost all will take longer to be eliminated from

the baby's immature system after the cord is cut. Bupivacaine and its

breakdown products in the circulation of babies for the first three

days have been found.

 

(5) Epidural anesthesia, used for cesareans, has also been associated

with more acidemia (acid blood levels) in healthy newborn babies than

has general anesthetic - an indication that epidurals can compromise

fetal blood and oxygen supply possibly through a drop in the mother's

blood pressure.

 

(6)Babies can become difficult to care later. Effect of hormonal

dysfunctions and/or drug toxicity.

 

Though points (1) through (6) involve direct effect on labor progress

amd quality, following information also becomes important for the

mother to decide in favor of pain for a short while or pain for long

time later.

 

(7)Insertion of an epidural needle or catheter into the epidural

space may cause traumatic bleeding into the epidural space. Clotting

abnormalities may lead to the development of a large haematoma

leading to spinal cord compression.

 

(8) The sympathetic blockade produced by epidurals, in combination

with uncorrected hypovolaemia, may cause profound circulatory

collapse.

 

 

(9) Patients with cardiovascular abnormalities are unable to increase

their cardiac output in response to the peripheral vasodilatation

caused by epidural blockade, and may develop profound circulatory

collapse which is very difficult to treat.

 

(10) Those taking anti-coagulants should not ask for epidurals.

Several other drugs are contra-indications, but is there time

available to allow stopping of those drugas for 1-2 days before

taking up emergency C-sections needed sometimes?

 

(11) As a result of vasodilatation of resistance and capacitance

vessels, relative hypovolaemia and tachycardia, with a resultant drop

in blood pressure. This is exacerbated by blockade of the sympathetic

nerve supply to the adrenal glands, preventing the release of

catecholamines. If blockade is as high as T2, sympathetic supply to

the heart (T2-5) is also interrupted and may lead to bradycardia. The

overall result may be inadequate perfusion of vital organs and

measures are required to restore the blood pressure and cardiac

output, such as fluid administration and the use of vasoconstrictors.

This is important in obstetric procedures.

 

(12) Nerve supply to the adrenals is blocked leading to a reduction

in the release of catecholamines. Urinary retention is a common

problem with epidural anaesthesia. A severe drop in blood pressure

may affect glomerular filtration in the kidney if sympathetic

blockade extends high enough to cause significant vasodilatation.

 

MOst important are effects on cardiovascular physiology during labor.

Aortocaval compression by the gravid uterus in the supine position

leads to hypotension due to compression of the inferior vena cava,

which results in diminished venous return and a drop in cardiac

output. Epidural blockade, with its attendant sympathetic blockade,

exacerbates the hypotension by causing peripheral vasodilatation.

Compression of the aorta also reduces uterine blood flow, and it is

thus clear that the combination of aortocaval compression and

epidural blockade can have a profound effect on uterine and therefore

placental blood flow.

 

The supine position should be avoided in pregnant women undergoing

epidural analgesia and anaesthesia, and the patient should be in a

lateral (preferably left) or tilted position at all times. Are these

helpful for C-section?

 

If uterine and placental blood flow is compromised, jeopardizing the

very function (delivery) epidural is suppoded to help! Is not this

compromised blood flow responsible for loss of pushing ability, and

the resultant Syntocino administration causing faster and abnormal

uterine contractions, giving no time for the fetus to recover and

produce abnormal heart rate patterns. Thus situation is ideal for C-

section or foreceps intevention.

 

Serious complications may occur with epidural anaesthesia. Facilities

for resuscitation should always be available whenever epidural

anaesthesia is performed. These facilities in plain vision make a

laboring woman panicky.

 

Hypotension has been common both in labour and when used for

Caesarean Section, and should be corrected promptly using fluid and

vasopressors. The presenting symptom of hypotension is often nausea,

which may occur before a change in blood pressure has even been

detected.

 

Total spinal, a rare complication occurring when the epidural needle,

or epidural catheter, is advanced into the subarachnoid space without

the operator's knowledge, and an "epidural dose" e.g. 10-20 ml of

local anaesthetic is injected directly into the CSF. The result is

profound hypotension, apnoea, unconsciousness and dilated pupils as a

result of the action of local anaesthetic on the brainstem. The use

of a test dose should prevent most cases of total spinal, but cases

have been described where the epidural initially appeared to be

correctly sited, but subsequent top-up doses caused the symptoms of

total spinal. This has been ascribed to migration of the epidural

catheter into the subarachnoid space, although the precise mechanism

is uncertain.

 

Accidental dural puncture is usually easily recognised by the

immediate loss of CSF through the epidural needle. This complication

occurs in 1-2% of epidural blocks, although it is more common in

inexperienced hands. It leads to a high incidence of post dural

puncture headache, which is severe and associated with a number of

characteristic features. The headache is typically frontal,

exacerbated by movement or sitting upright, associated with

photophobia, nausea and vomiting, and relieved when lying flat. Young

patients, especially obstetric patients, are more susceptible than

the elderly. Where the headache is severe, or unresponsive to

conservative measures, an epidural blood patch may be used to treat

the headache.

 

Epidural haematoma is a rare but potentially catastrophic

complication of epidural anaesthesia. The epidural space is filled

with a rich network of venous plexuses, and puncture of these veins,

with bleeding into the confined epidural space, may lead to the rapid

development of a haematoma which may lead to compression of the

spinal cord, and can have disastrous consequences for the patient

including paraplegia. For this reason, coagulopathy or therapeutic

anticoagulation with heparin or oral anticoagulants has long been an

absolute contraindication to epidural blockade.

 

Further reading:

Sharrock NE, Haas SB, Hargett MJ et al. Effects of epidural analgesia

on the incidence of deep vein thrombosis after total knee

arthroplasty. Journal of Bone and Joint Surgery American Volume

1991;73:502-6.

Dalldorf PG, Perkins FM, Totterman S, Pellegrini VD. Deep venous

thrombosis following total hip arthroplasty. Effects of prolonged

postoperative epidural analgesia. Journal of Arthroplasty 1994;9:611-

6.

Perler BA, Christopherson R, Rosenfeld BA et al. The influence of

anaesthetic method on infrainguinal bypass graft patency: a closer

look. American Journal of Surgery 1995;61:784-9.

Bach S, Noreng MF, Tjellden NU. Phantom limb pain in amputees during

the first 12 months following limb amputation, after preoperative

lumbar epidural blockade. Pain 1988;33:297-301.

Yeager MP, Glass DD, Neff RK, Brinck-Johnsen T. Epidural anaesthesia

and analgesia in high-risk surgical patients. Anesthesiology

1987;66:729-36.

Bromage PR. Continuous Epidural Analgesia. In "Epidural Analgesia"

Bromage PR (ed) W.B. Saunders 1978 p. 237-8.

Mulroy MF. Epidural opioid delivery methods: bolus, continuous

infusion, and patient-controlled epidural analgesia. Regional

Anaesthesia 1996;21:100-4.

Ngan Kee WD. Epidural pethidine: pharmacology and clinical

experience. Anaesthesia and Intensive Care 1998;26:247-55.

Horlocker TT, Wedel DJ. Spinal and epidural blockade and

perioperative low molecular weight heparin: smooth sailing on the

Titanic (editorial). Anesthesia and Analgesia 1998;86:1153-6.

Rodgers A, Walker N, Schug S et al. Reduction of postoperative

mortality and morbidity with epidural or spinal anaesthesia: results

from overview of randomised trials. British Medical Journal

2000;321:1493-7

 

[Most of above information is educational nature and is provided by

Dr Leon Visser,

Dept. of Anesthesiology, University of Michigan Medical Center, Ann

Arbor, Michigan, USA

World Federation of Societies of Anaesthesiologists

Full information can be read at:

http://www.nda.ox.ac.uk/wfsa/html/u13/u1311_01.htm

 

 

 

The attitudes are changing. How to save life using non-invasive

techniques appears to be the theme of research efforts. For instance,

 

The hypotension, resultant fetal distress etc appears to be

correctible by simple measures:

 

Techniques Confirmed to Improve Fetal Oxygen Status During Labor

By Anthony J. Brown, MD

 

NEW YORK (Reuters Health) Jun 03 - Researchers have shown that three

intrauterine resuscitation techniques commonly used to improve fetal

oxygen status during labor are indeed useful when the fetal heart

rate (FHR) pattern is nonreassuring.

These techniques are: giving the mother an IV fluid bolus of 1000 mL,

placing her in a lateral position, and administering O2 at 10 L/min

with a non-rebreather face mask.

 

In fact, these procedures "have become the legal standard," lead

author Dr. Kathleen Rice Simpson, from St. John's Mercy Medical

Center in St. Louis, commented to Reuters Health. "If you don't use

them when the fetus is in trouble, people will say that you've

violated the standard of care."

 

Ironically, there are actually few data to show these interventions

are effective, Dr. Simpson said. "There isn't a lot of evidence to

support these measures, they're just intuitively thought to benefit

the fetus."

Dr. Simpson and her colleague Dr. Dotti C. James assessed the effects

of IV fluid bolus, positioning, and O2 administration on fetal oxygen

status in around 50 women. All of the women were healthy,

nulliparous, and had reassuring FHR patterns.

 

An IV fluid bolus of 1000 mL was significantly better than 500 mL at

improving fetal oxygen saturation (FSpO2), the investigators note.

Likewise, lateral positioning and O2 administration also

significantly improved FSpO2.

"I had expected O2 use to be beneficial, but I was surprised that the

IV fluid bolus also worked," Dr. Simpson noted.

Although the study involved women with reassuring FHR patterns, Dr.

Simpson said she expected the improvement in FSpO2 to be even more

pronounced with nonreassuring patterns.

Ethical issues precluded doing this initial study in women with

nonreassuring FHR patterns, but given the current findings she said

her team is now planning a study in such patients.

Obstet Gynecol 2005;105:1362-1368.

 

 

 

ayurveda, durgesh mankikar

<d_mankikar> wrote:

> Dr Bhate,

>

> It is easy to tell a woman to bear the pain, but only she would

know if it is bearable or not. Many that did not want an epidural,

ask for it, when faced with that pain. Men can argue this point

however, only women who have delivered can really speak on this

issue. Again, personal experiences are personal biases. if you had a

quick delivery, with no complications, one might think that the

epidural may not have been necessary. If one had a prolonged delivery

and lot of pain, one would thank the epidural for painless or reduced

pain during the process, and if one has a complication, then one

tends to blame everything that happened.

>

[Guest guest]

Dear Sir,

 

Thanks very much for your valuable insights. I totally endorse most of what you

have written in your post. As someone who had being administered epidural

anesthesia herself due to fetal distress, I would like to mention one permanent

and rather damaging effect of this anesthisia which is back pain. The site where

epidural was administered for me has been paining constantly for the past 1.5

yrs . After haven given the same, my gynaec had made me life down constantly and

sometimes I feel very cheated that I was not allowed to go through the natural

process of birthing at all, my pain tolerance level is not that low I guess but

if I was made to lie down constantly during my labour (citing the reasons that

my baby had gone up in the birth passage because of water breaking) , how could

a natural delivery ever be possible? I didnt realise all this back then as I

guess its a life and death situation for every woman going through childbirth.

As they rightly say, childbirth is a whiff of

second life for a woman!!

 

As of today, no amount of moov massage or regular massing has been able to

relieve that....That is one nagging pain I always have to suffer throughout my

life I guess....I would request you all to learn from my experience and always

have the power and control to decide whats right and whats not for you. However

good or efficient your doctor maybe, make sure you're the one who decides for

you and not the doctor!!

 

As for me, the greatest relief I have was that my baby arrived absolutely

healthy and happy :-)

 

Regards

Bhairvi

 

 

> Epidural anasthesia has been successfully used in surgery, >

obstetrics and pain control, as it permits continuous anaesthesia