OB-LEA-Mng - Management of Labor Epidural Tools of the Trade Dmitry Portnoy MD Anesthesiology Department Q When is the best time to get an epidural

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Management of Labor Epidural: Tools of the Trade Dmitry Portnoy, MD Anesthesiology Department
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www.babiescantread.com/maternitees.htm Q: When is the best time to get an epidural? A: Right after you find out you're pregnant.
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Intensity of Pain in Labor http://www.manbit.com/oa/oaindex.htm
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Physiology of Pain in Labor 1 st stage of labor – mostly visceral Dilation of the cervix and distention of the lower uterine segment Dull, aching and poorly localized Slow conducting, visceral C fibers, enter spinal cord at T10 to L1 2 nd stage of labor – mostly somatic Distention of the pelvic floor , vagina and perineum Sharp, severe and well localized Rapidly conducting A-delta fibers, enter spinal cord at S2 to S4 T 10 L 1 S 2 S 4 http://www.manbit.com/oa/oaindex.htm
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Anatomy of the Epidural Space Boundaries of epidural space Superior - the foramen magnum Inferior - the sacral hiatus and sacro- coccygeal membrane Anterior - the posterior longitudinal lig. Posterior - periosteum of laminae of the vertebrae and the lig. flavum Lateral - periosteum of the pedicles and intervertebral foraminae Epidural space contains: Dural sac and nerve roots Blood vessels and lymphatics Connective and fatty tissue From Cousins, Neural Blockade
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Spread of Epidurally Injected Solutions Drugs must travel through: dura matter arachnoid matter CSF pia matter white matter gray matter Rapid access via “dural cuff” Competing pathways: Uptake into epidural epidural fat Uptake into systemic circulation From Cousins, Neural Blockade
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The Perfect Labor Epidural Safe (for both mother and fetus) Easy and painless placement Fast onset, easy administration, tight control Effective analgesia (for both stage I and II) Reliable extension for indicated procedures Minimal side effects (for both mother and fetus) No adverse effects on labor progress Minimal complications High patient satisfaction overall SAFETY COMES FIRST
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Terms and Incidence of Unsatisfactory Epidural Block Term Incidence Author Year Initial failure rate 4.2% Dill-Russel P. 2001 Catheter failure rate 13.1% Eappen S. 1998 Epidural replacement rate 14.3 Segal S. 1997 Failure to produce anesthesia 4.1% Tanaka K 1993 Failed or inadequate block 0.9 to 13.1% Douglas J 2000 Failure to produce a block 1.2% Norris MC 1998 “Spotty” or unilateral anesthesia 8.2% Ducrow 1971 Inadequate anesthesia 18%
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This note was uploaded on 12/28/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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OB-LEA-Mng - Management of Labor Epidural Tools of the Trade Dmitry Portnoy MD Anesthesiology Department Q When is the best time to get an epidural

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