What’s New in Neuraxial Labor Analgesia

Abstract

Purpose of Review This article provides an update of recent practice trends in neuraxial labor analgesia. It reviews available evidence regarding management of labor pain in obstetric patients with COVID-19, serious adverse events in obstetric anesthesia to help inform risk/benefit decisions, and increasingly popular neuraxial labor analgesia techniques and adjuvants. State-of-theart modes of epidural drug delivery are also discussed. Recent Findings There has recently been a focus on several considerations specific to obstetric anesthesia, such as anesthetic management of obstetric patients with COVID-19, platelet thresholds for the safe performance of neuraxial analgesia in obstetric patients with thrombocytopenia, and drug delivery modes for initiation and maintenance of neuraxial labor analgesia. Summary Neuraxial labor analgesia (via standard epidural, dural puncture epidural, and combined spinal epidural techniques) is the most effective therapy to alleviate the pain of childbirth. SARS-CoV-2 infection is not, in and of itself, a contraindication to neuraxial labor analgesia or cesarean delivery anesthesia. Early initiation of neuraxial labor analgesia in patients with COVID-19 is recommended if not otherwise contraindicated, as it may reduce the need for general anesthesia should emergency cesarean delivery become necessary. Consensus regarding platelet thresholds for safe initiation of neuraxial procedures has historically been lacking. Recent studies have concluded that the risk of spinal epidural hematoma formation after neuraxial procedures is likely low at or above an imprecise range of platelet count of 70-75,000 × 10 6 /L. Thrombocytopenia has been reported in obstetric patients with COVID-19, but severe thrombocytopenia precluding initiation of neuraxial anesthesia is extremely rare. High neuraxial blockade has emerged as one of the most common serious complications of neuraxial analgesia and anesthesia in obstetric patients. Growing awareness of factors that contribute to failed conversion of epidural labor analgesia to cesarean delivery anesthesia may help avoid the risks associated with performance of repeat neuraxial techniques and induction of general anesthesia after failed epidural blockade. Dural puncture techniques to alleviate the pain of childbirth continue to become more popular, as do adjuvant drugs to enhance or prolong neuraxial analgesia. Novel techniques for epidural drug delivery have become more widely disseminated. Keywords COVID-19 . Anesthesia and analgesia . Neuraxial anesthesia . Epidural analgesia . Dural puncture epidural . Single-shot spinal . Postpartum hemorrhage . Combined spinal epidural . Patient-controlled epidural analgesia . Programmed intermittent epidural bolus . Sterile precautions . Powered air-purifying respirator . Venous thromboembolism prophylaxis . Wire-reinforced epidural catheter . Accidental dural puncture . Postdural puncture headache . Epidural blood patch . Chronic headache . Immune thrombocytopenic purpura . Immune thrombocytopenia . Gestational th...

Association of Medicaid Expansion With Neuraxial Labor Analgesia Use in the United States: A Retrospective Cross-Sectional Analysis

“…9 Compared to nonneuraxial techniques, neuraxial analgesia is associated with lower pain scores and higher patient satisfaction scores. 10 Furthermore, an epidural catheter sited for labor analgesia allows rapid initiation of epidural anesthesia for operative vaginal delivery or intrapartum cesarean delivery, 11,12 thereby minimizing the need for general anesthesia and its associated risks, such as airway complications, inadequately controlled postoperative pain, and the need for neonatal resuscitation. 12 Understanding the extent to which Medicaid expansion has affected the use of neuraxial labor analgesia is important for several reasons.…”

“…10 Furthermore, an epidural catheter sited for labor analgesia allows rapid initiation of epidural anesthesia for operative vaginal delivery or intrapartum cesarean delivery, 11,12 thereby minimizing the need for general anesthesia and its associated risks, such as airway complications, inadequately controlled postoperative pain, and the need for neonatal resuscitation. 12 Understanding the extent to which Medicaid expansion has affected the use of neuraxial labor analgesia is important for several reasons. First, small health care costs, specifically for prescription drugs, can influence patients' decision-making about their health care.…”

Reporte de caso: bloqueo neuroaxial alto tras la utilización de dosis test en analgesia del parto

“…Por otra parte, las técnicas basadas en catéteres otorgan una rápida conversión a anestesia quirúrgica para operación cesárea, minimizando la necesidad de anestesia general y por tanto de los riesgos asociados. En este sentido, el catéter epidural normofuncionante es un elemento de seguridad anestésica [5], [3], [6].…”

“…Pese a la seguridad y los beneficios que ofrecen las técnicas neuroaxiales, es importante conocer las complicaciones, que aunque en las pacientes embarazadas sanas y jóvenes laa frecuencia de es menor que en otras categorías, pueden ser graves [5], [7], [8], [9], [10], [11], [12].…”

“…El bloqueo neuroaxial alto (BNA) ha sido identificado como una de las complicaciones más serias y común de la anestesia y analgesia neuroaxial (tanto espinal y epidural) en las pacientes obstétricas, siendo la causa más frecuente de paro cardíaco anteparto, con una incidencia de 1:4.336 procedimientos neuroaxiales [5], [13], [14]. Dentro de los factores de riesgo se encuentran la baja estatura, la obesidad, el embarazo y la deformidad raquídea [15].…”