Circulation 122,210 • Volume 34, No. 2 • October 2019   Issue PDF

PRO and CON: Using a Labor Epidural for Cesarean Delivery – PRO: Dose the Epidural for Surgical Anesthesia

Michael Block, MD

Related Article:

CON: Pull the Epidural Catheter and Perform a Spinal

EpiduralLabor patients requiring intrapartum cesarean delivery (CD) may present with an indwelling epidural catheter to anesthesia professionals on Labor and Delivery (L&D). Dosing the labor epidural to achieve surgical anesthesia should be considered as the first-line approach. Effective surgical anesthesia and postoperative analgesia can be accomplished using an in-situ epidural catheter, while acknowledging that an incomplete or one-sided level of anesthesia may occur.1

The use of an indwelling epidural catheter allows for rapid yet controlled titration of anesthetic medications to achieve surgical anesthesia. For example, administration of local anesthetics (e.g., lidocaine 2% with epinephrine and sodium bicarbonate, or 3% 2-chloroprocaine) in combination with a lipophilic opioid (e.g., fentanyl, hydromorphone) typically provides rapid onset of surgical anesthesia.2 In clinical circumstances where avoidance of abrupt sympathetic blockade is necessary (e.g., reduced volume status, limited cardiac reserve), gradual titration of anesthesia using an epidural catheter is a key advantage over spinal anesthesia alone.

In the event that the CD outlasts the duration of the initial epidural loading dose, the level of anesthesia can be maintained or extended using further local anesthetic administered through the epidural catheter. Examples may include a CD where the time for surgical exposure is prolonged due to adhesions, morbid obesity, or placental pathology.3 For unanticipated complications such as postpartum hemorrhage requiring return to the operating room for re-exploration or hysterectomy, maintaining the epidural catheter allows for the redosing of epidural anesthesia, thus potentially precluding general anesthesia and its inherent risks.4 An added benefit of maintaining the epidural postoperatively is the ability to provide appropriate analgesia with patient-controlled epidural analgesia using a dilute solution of local anesthetic and opioid.

A known challenge with relying on an indwelling epidural catheter for CD is failure to achieve adequate anesthesia.5 However, measures taken during epidural placement can maximize the successful conversion from labor epidural analgesia to surgical anesthesia. For example, the use of combined-spinal epidural dosing and/or dural puncture epidural may increase the reliability of epidural catheter insertion and enhance the effectiveness of medications administered through an epidural.6

The effective management of labor epidural analgesia relies on effective communication and coordination of care between anesthesia and obstetric professionals in L&D. Since a labor epidural catheter remains indwelling for prolonged periods of time without an anesthesia professional in continuous attendance, it is important that inadequate analgesia is promptly brought to the attention of anesthesia professionals so necessary interventions (catheter bolus, adjustment, or replacement) are undertaken.7,8 Ensuring a functional epidural catheter during labor can reduce the need for a repeat neuraxial block or conversion to general anesthesia particularly when under time pressure for urgent CD.

Finally, administration of spinal anesthesia for intrapartum CD subsequent to an infusion through an epidural catheter carries risks of high or total spinal given the uncertain amount of drugs in the neuraxial space that were administered.1 Moreover, conversion to general anesthesia in lieu of dosing an indwelling epidural catheter, introduces further risks associated with instrumenting the maternal airway and increasing maternal and neonatal exposure to anesthetic agents.

When a laboring patient receiving epidural analgesia presents for CD, anesthesia professionals should utilize the epidural catheter for surgical anesthesia as opposed to abandoning use of the epidural and proceeding with spinal or general anesthesia. Approaches to promote effective use of epidural anesthesia such as combined spinal epidural or dural puncture epidural are described above. When clinically applied as the first-line approach, the added risks of performing spinal or general anesthesia for CD or additional postpartum procedures such as tubal ligation can be averted.

 

Dr. Block is director, Obstetric Anesthesiology, and is Residency Program Director in the Department of Anesthesiology, Hackensack University Medical Center, Hackensack, NJ.

The author has no conflicts of interest to disclose.

References

  1. Carvalho B. Failed epidural top-up for cesarean delivery for failure to progress in labor: the case against single-shot spinal anesthesia. Int J Obstet Anesth. 2012; 21:357–359.
  2. Aiono-Le Tagaloa L, Butwick AJ, Carvalho B. A survey of perioperative and postoperative anesthetic practices for cesarean delivery. Anesthesiol Res Pract. 2009; 2009: 510642.
  3. Hillyard SG, Bate TE, Corcoran TB, et al. Extending epidural analgesia for emergency caesarean section: a meta-analysis. Br J Anaesth. 2011;107:668–678.
  4. Butwick AJ, Carvalho B, Danial C, Riley E. Retrospective analysis of anesthetic interventions for obese patients undergoing elective cesarean delivery. J Clin Anesth. 2010; 22:519–526.
  5. Hawkins JL, Chang J, Palmer SK, et al. Anesthesia-related maternal mortality in the United States: 1979-2002. Obstet Gynecol. 2011; 117:69–74.
  6. Cappiello E, O’Rourke N, Segal S, Tsen LC. A randomized trial of dural puncture epidural technique compared with the standard epidural technique for labor analgesia. Anesth Analg. 2008;107:1646–1651.
  7. Halpern SH, Soliman A, Yee J, Angle P, Ioscovich A. Conversion of epidural labour analgesia to anaesthesia for caesarean section: a prospective study of the incidence and determinants of failure. Br J Anaesth. 2008;102:240–243.
  8. The Joint Commission: Preventing infant death and injury during delivery. Sentinel Event Alert, Issue 30, Jul. 21, 2004. https://www.jointcommission.org/sentinel_event_alert_issue_30_preventing_infant_death_and_injury_during_delivery/ Accessed March 25, 2019.