CHALLENGES OF
EPIDURAL ANESTHETIC AND ITS ROLE IN LABOR
You are listening to ReachMD XM160, The Channel for
Medical Professionals. Welcome to Advances in Women's Health, sponsored in
part by Eli Lilly. Your host is Dr. Lisa Mazzullo, Assistant Professor of
Obstetrics and Gynecology at Northwestern University Medical School, The
Feinberg School of Medicine.
You are listening to ReachMD, The Channel for Medical
Professionals. Welcome to Advances in Women's Health. I am Dr. Lisa Mazzullo,
your host and with me today is Dr. Cynthia Wong, an Associate Professor of
Anesthesia at Northwestern University Medical School and the Medical Director
of Obstetrical Anesthesia at Prentice Women's Hospital.
DR. LISA MAZZULLO:
Welcome Dr. Wong.
DR. CYNTHIA WONG:
Thank you.
DR. LISA MAZZULLO:
So, to begin with, I think epidural anesthesia seems like a
gift to patients in labor. Do you want to may be talk a little bit about what
the difference is or the different types of epidural that are available?
DR. CYNTHIA WONG:
Sure. Well, labor hurts as we all know and it hurts a lot.
There are different types of epidurals that we can use to remedy that.
Traditionally, back in the old days and we are talking about 30 years ago, as
you said in the 1970s, we did epidurals with local anesthetics. The local
anesthetic we usually used was bupivacaine and we infused it either
intermittently or continuously and women got nice and numb from their umbilicus
and down, but it was also associated with a significant degree of motor
blockade, which was uncomfortable for women. They felt like _____, they
couldn’t really move around in bed and it may have contributed to an increased
incidence of instrumental vaginal delivery. So, about 20 or 25 years ago,
somebody very bright discovered new opioidreceptors in the spinal cord
and discovered that if we added opioids to our local anesthetic mix, we could
cut down on the amount of local anesthetic that we administered and accomplish
2 things. Number 1, we would get better pain relief because we were kind of
addressing 2 different mechanisms of the pain – the pain that's mediated and
treated by local anesthetics, which is a somatic-type pain and the pain that is
mediated through new opioidreceptors. So, the advantages were we could
cut down the amount of local anesthetic, which cut down on the motor block,
which cut down on the uncomfortable feeling of not being able to move around in
bed.
DR. LISA MAZZULLO:
Which would improve pushing in labor, which was lovely.
DR. CYNTHIA WONG:
Correct and allowed some women to walk if they wanted to and
then we used lower doses of both drugs, so we used lower doses of local
anesthetics and lower doses of opioids, which means there is lower side effects
from each one of those drugs, both for the mom and the fetus.
DR. LISA MAZZULLO:
And you were talking briefly about the possibility of
walking and you know, there is quite a lot of lay press taking about walking
epidurals versus traditional epidurals. Can you may be comment a little bit
about what the advantage or disadvantage of those would be?
DR. CYNTHIA WONG:
Sure. Really, the walking epidurals what I just talked
about is the newer technique where we use low concentrations of local
anesthetic and combine it with opioid because if we just use low concentrations
of local anesthetic by itself, many women would have breakthrough pain and this
is the anesthetic that I think all modern day obstetric anesthesiologist should
be aiming for, whether or not a women gets up and walks. Some women when they
get pain relief during labor would prefer to take a nap, they really don’t want
to walk. Research has shown that walking doesn’t make any difference in terms
of the outcome of labor. In other words, it doesn’t decrease your risk of
having a C-section or a forceps delivery, but many women feel more comfortable
getting up and walking around, having the ability to go to bathroom.
DR. LISA MAZZULLO:
Is there any disadvantage to having a walking epidural?
DR. CYNTHIA WONG:
There really isn't except that we use lower doses of drugs
as I said and they won't be enough for some women. So, back in the old days,
we gave a much higher dose of drug and it made everybody comfortable. Now, we
give lower doses and they make most women comfortable, but there will still be
a few women, who will need the higher doses and will need a little bit more
attention. It's not a big deal. We just go back and individualize the
anesthetic much more than we used to.
DR. LISA MAZZULLO:
When we are thinking about early labor, the anesthetics for
that time have changed, I think, a lot from research you have done, which we
will talk a little about in a minute, but opioids were often used in early
labor and I was wondering if you could comment a little bit about the
advantages or disadvantages of using intrathecal analgesia over a systemic
analgesia in early labor.
DR. CYNTHIA WONG:
So, we used to give a lot of systemic analgesia, opioid
analgesia early in labor and the belief that if we gave an epidural too early,
it would slow things down and cause C-section and you know, systemic opioids do
not work very well for labor pain. They make women sleepy, they make women
groggy, they throw up a lot. We have the illusion may be that it provides a
little bit of analgesia, but when you go in there and actually study it, there
are some studies that show that you really don’t get any significant analgesia
out of systemic opioids at all.
DR. LISA MAZZULLO:
They would feel sleepier during it happening, but not feel
real relief.
DR. CYNTHIA WONG:
Right and the other problem is that it actually might make
things worse because what happens is women hyperventilate during contractions,
that actually decreases uterine blood flow, which is not a bad thing for someone
who has normal uteroplacental perfusion, but could be an issue in someone who
has decreased uteroplacental perfusion and then in between contractions because
they've hyperventilated during the contraction, they hypoventilate, which is
made worse when you have narcotics on board and then hypoventilation could
conceivably lead to maternal hypoxemia, which would lead to fetal hypoxemia and
so you get in kind of the worst of both worlds here.
DR. LISA MAZZULLO:
Hmm.
DR. CYNTHIA WONG:
You are not getting pain relief and you are hypoventilating.
DR. LISA MAZZULLO:
One of the challenges, I think, you must find when you do
the research you are doing is how do patients really perceive pain because I
think it's really a subjective rather than objective thing and I know there are
some ways you have come up with measuring that. Can you comment a little bit
about how you have dealt with that problem?
DR. CYNTHIA WONG:
Well, you are absolutely right. Pain is extremely
multidimensional. Our little VRS score (Verbal Rating Score) 0 to 10 is mostly
inadequate, although easy to use and so we use it quite frequently, but you
know we tell patients 10 is the worst pain you could ever imagine and most
people can't imagine the worst pain imaginable. So, we have all had the
experience where women say they are 8 on a 10 scale and you think yourself oh!
dear, you don’t really know what it is going to get, what it is going to be
like.
DR. LISA MAZZULLO:
Exactly.
DR. CYNTHIA WONG:
And interestingly enough, women usually ask further
epidurals when they have the same pain score. It's usually about 7 or 8 out of
10, but when they get to 8 or 10 cm, they are still 7 or 8 out of 10. We all
know that it hurts more as labor progresses, so you can see right there that
this pain score is inadequate in estimating pain. There have been a few
studies that have been done too. There was the interesting study that came out
of Israel a couple of years ago and in this particular hospital in Israel, the
caregivers are Jewish physicians and nurses and there was a Jewish patient
population and a Bedouin patient population and what they have the care
providers do is assess the pain that the women were feeling in labor and then
they asked the women how much pain they were feeling in labor and interestingly
enough the caregivers thought that the Jewish women hurt a lot more than the
Bedouin women hurt during labor. Their pain scores were much higher, but if
you ask the women, they perceive that they were feeling the same amount of
pain.
DR. LISA MAZZULLO:
Interesting.
DR. CYNTHIA WONG:
So, we really also have an issue in how we perceive women
are in pain and how we assess that.
DR. LISA MAZZULLO:
So, what would you suggest we do know?
DR. CYNTHIA WONG:
Well, some of my colleagues at other institutions are trying
to develop multidimensional pain scores, not ready to use yet, not validated
clinically. It's hard to make them so they are useful clinically because
really if you evaluate all the dimensions of pain, it would take us 15 minutes
to evaluate everybody for pain and we all know we don’t have that kind of
time. So, I think now you just have to sit down for a few minutes with the
patient and figure out what's going on. Is it pain, is it anxiety, what's
contributing to their feeling of not being comfortable.
DR. LISA MAZZULLO:
If you are just tuning in, you are listening to Advances in
Women's Health on ReachMD, The Channel for Medical Professionals. I am Dr.
Lisa Mazzullo and I am speaking today with Dr. Cynthia Wong and we are
discussing the challenges of epidural anesthesia and its effect on labor and
patient care.
Dr. Wong, the next thing I want to address is some of the
information that came out of your study regarding early epidural usage in labor
and its lack of impact on cesarean section and labor progress and first tell us
who were the patients you included in this study?
DR. CYNTHIA WONG:
So, the original study that was published a couple of years
ago included patients, who were having baby for the first time, the nulliparous
patients, in early labor. They had asked for pain relief before their cervix
was dilated 4 cm.
DR. LISA MAZZULLO:
Did you find there was an impact on using epidural
anesthesia earlier as far as the course of labor or the result of the labor
delivery mode?
DR. CYNTHIA WONG:
So, there was no difference in the cesarean delivery rate
between giving women what was called a combined spinal epidural early in labor
compared to giving them systemic opioid. Labor was actually faster in the
women, who got the epidural early in labor and it was faster by a lot, by a
median of 80 minutes. Obviously, the pain relief is much better. The
incidence of nausea and vomiting was much lower in the group that got the
neuraxial analgesia early in labor and the one-minute Apgar scores for the
babies were higher in the women, who got the neuraxial analgesia compared to
the systemic opioid analgesia, which I found interesting since the opioid was
early in labor. For most women, that was a good 4 or 5 hours before delivery,
but we still seemed to have an opioid effect on the neonate at delivery.
DR. LISA MAZZULLO:
Was there anything else that had an impact? Did the use of
Pitocin make any difference and which group had better labor progress?
DR. CYNTHIA WONG:
Well, at our institution, as you know, most women get
Pitocin during labor. That's just the way my obstetric colleagues practice,
but interestingly enough, the women who were randomized to the systemic opioid
group got more oxytocin. So, their labors were slower despite the fact that
they had more oxytocin.
DR. LISA MAZZULLO:
In nulligravid patients, obviously labor is typically a
fairly long period of time to begin with. Do you have any concerns about the
catheter or the medication usage over longer periods of time in the patient for
either the mother or the baby?
DR. CYNTHIA WONG:
You know, not really. We use fairly low doses and so the
duration is not a major factor. It's true that the longer you leave an epidural
catheter in place, the higher the infection risk, but we are talking about days
compared to hours.
DR. LISA MAZZULLO:
Hmm.
DR. CYNTHIA WONG:
So, leaving it in 6 compared to 8 hours is not a big deal.
DR. LISA MAZZULLO:
And are there any clinical scenarios where we would not be
able to use an epidural anesthetic in this scenario?
DR. CYNTHIA WONG:
Well, epidural analgesia is absolutely contraindicated
obviously by patient refusal. We also do not put it in patients who have a
coagulopathy or taking anticoagulants. If there would be bleeding in the
epidural space, it's a closed space surrounded by bone, the hematoma can't go
anywhere and so we would get compression of nerves or spinal cord tissue and
that could be catastrophic. So, we don’t put it in people who have a
coagulopathy.
DR. LISA MAZZULLO:
Thanks to Dr. Cynthia Wong, who has been our guest and we
have been discussing the challenges of epidural anesthetic and its role in
labor.
I am Dr. Lisa Mazzullo. You have been listening to
Advances in Women's Health on ReachMD, The Channel for Medical Professionals.
Please visit our website at reachmd.com, which features our entire library
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Thank you for listening to Advances in Women's Health,
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