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Adverse effects of neuraxial analgesia and anesthesia for obstetrics
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Official reprint from UpToDate® www.uptodate.com
Adverse effects of neuraxial analgesia and anesthesia for obstetrics Author Gilbert J Grant, MD
Section Editor David Hepner, MD
Deputy Editor Vanessa A Barss, MD
Last literature review for version 17.1: enero 1, 2009 | This topic last updated: enero 28, 2009 INTRODUCTION — Regional anesthetic techniques, such as epidural and spinal anesthesia, provide the most effective means of pain relief during labor, which is likely the most severe pain that a woman experiences during her lifetime [1]. The prevention and treatment of adverse effects of these techniques will be reviewed here. Specific issues related to pain management of labor and delivery and administration of neuraxial anesthesia are discussed separately. (See "Pharmacologic management of pain during labor and delivery" and see "Neuraxial analgesia and anesthesia for labor and delivery: Techniques"). SYSTEMIC TOXICITY — Systemic toxicity of local anesthetics is related to high plasma drug concentrations. The most common etiology is accidental injection of local anesthetic into a blood vessel. Systemic toxicity manifests in the central nervous system (CNS) as tinnitus, disorientation, and (ultimately) seizures; in the cardiovascular system toxicity manifests as hypotension, dysrhythmias, and cardiac arrest. CNS toxicity typically precedes cardiovascular toxicity, thus patients may experience cerebral signs without hemodynamic compromise. Bupivacaine toxicity does not adhere to this sequence; cardiac toxicity may occur in the absence of CNS toxicity [2]. High plasma drug levels may cause systemic toxicity after epidural administration, but are unlikely after spinal administration because lower doses of drug are given. The likelihood of systemic toxicity can be reduced by aspirating the catheter before injecting to help ascertain that its distal aperture(s) is (are) not located within a blood vessel. Other measures to reduce the risk of toxicity include adding epinephrine to the solution to delay intravascular absorption, using a test dose, injecting a local anesthetic with a lower toxicity profile, reducing the total dose injected, and administering the dose incrementally. If CNS signs of local anesthetic toxicity develop, the injection should be stopped immediately. Seizures cay be treated with a small dose of benzodiazepine (eg, midazolam 2 to 5 mg) or barbiturate (eg, thiopental 50 to 75 mg). Oxygen should be administered, as seizure activity increases maternal oxygen consumption, which will decrease oxygen delivery to the fetus. The patient should be protected from injuring herself during the seizure. In the event of cardiovascular toxicity, advanced cardiac life support (ACLS) should be provided with certain considerations specific to local anesthetic toxicity. Airway management is critical, as cardiotoxicity is exacerbated by hypercapnia, hypoxia, and acidosis. Dysrhythmias are difficult to control, especially those resulting from bupivacaine toxicity. Currently, amiodarone, a primary drug in the ACLS arrhythmia treatment algorithm, is the favored treatment for severe bupivacaine-induced arrhythmias [3]. Early administration of lipid emulsion is another component in resuscitation of bupivacaine-induced cardiotoxicity. However, the dysrhythmias are often recalcitrant to therapy; emergency cardiopulmonary bypass may be lifesaving until the drug dissociates from cardiac tissue [4]. Treatment of hypotension with vasopressin, 40 units IV, rather than epinephrine is preferred because epinephrine may exacerbate local anesthetic-induced arrhythmias. Other drugs that should be avoided in the management of local anesthetic induced cardiotoxicity include calcium channel
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blockers and phenytoin as both may worsen local anesthetic induced toxicity. (See "Overview of advanced cardiovascular life support in adults" and see "Neuraxial analgesia and anesthesia for labor and delivery: Drugs", section on Bupivacaine). Use of test dose — After insertion of an epidural catheter, a small test dose may be injected to exclude intravascular or intrathecal placement. A typical test dose is 3 mL of 1.5 percent lidocaine with 1:200,000 epinephrine (ie, 45 mg lidocaine and 15 mcg epinephrine). The patient is monitored for signs and symptoms of intravascular or intrathecal injection. If this test dose is injected intravascularly, the lidocaine produces tinnitus, circumoral numbness, a metallic taste, and dizziness, and the beta-1 adrenergic agonist effect of epinephrine results in tachycardia. However, the wide variations in heart rate that occur with labor pain may mask epinephrine-induced increases in heart rate. Thus, to maximize sensitivity, the test dose should be administered immediately after a uterine contraction. The subjective sensation of palpitations is a reliable symptom of intravascular administration, irrespective of the monitored heart rate. Intrathecal injection of the test dose causes rapid onset of dense lower extremity motor block. The choice of drug and need for a test dose are controversial. As an example, epinephrine's alpha adrenergic effects may produce uterine artery constriction and decrease placental blood flow. Substituting a pure beta adrenergic agonist (eg, isoproterenol) would avoid utero-placental vasoconstriction if intravascular injection were to occur. Alternatively, air may be used for the test dose because intravascular injection of 0.5 to 1 mL of air is easily appreciated as a characteristic "swishing" sound by Doppler monitoring of the maternal precordium. The low concentration of local anesthetics currently used for epidural analgesia techniques for labor are unlikely to cause untoward effects if they are accidentally injected intravascularly. Under these circumstances, the test dose is more likely to be used to recognize accidental intrathecal injection of local anesthetics. Furthermore, the introduction of softer, more flexible epidural catheters have decreased the incidence of venous cannulations from 5.7 to 1.1 percent [5]. For this reason, some anesthesiologists have abandoned the intravascular test dose when very low concentrations of local anesthetics are used. Many anesthesiologists do not use an intravascular test dose with "walking epidural" solutions because they are inherently safe since they are so dilute. Furthermore, a test dose of 3 mL of 1.5 percent lidocaine with 1:200,000 epinephrine may produce motor block, an effect that is undesirable during labor. Another undesirable side effect of the 1.5 percent lidocaine with 1:200,000 epinephrine test dose is maternal hypotension, which is less likely to occur if the test dose is omitted before the dilute "walking epidural" solution is administered. However, the use of a 3 mL test dose is essential when administering more concentrated solutions of local anesthetic, such as 2 percent lidocaine with epinephrine for a cesarean delivery. When relatively high concentrations of local anesthetics are administered, a test dose should always be used. Allergic reactions — (See "Allergic reactions to local anesthetics"). HIGH SPINAL — A high spinal refers to more cephalad progression of the level of anesthesia than planned when the neuraxial block was administered. The outcome can be disastrous if the situation is not recognized and corrected immediately. Consequences of high spinal may include: Massive sympathectomy that results in hypotension. Block of the cardiac accelerator fibers (T1 to T4), which inhibits compensatory tachycardia. Hypoperfusion of the brainstem causing respiratory depression and nausea. Dyspnea resulting from anesthesia of the chest. Complete diaphragmatic paralysis if the C3 to C5 roots are blocked. Aspiration of gastric contents due to loss of consciousness and compromise of airway reflexes. One cause of high spinal is accidental intrathecal injection of a local anesthetic dose intended for the
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epidural space. This is a potential problem when high concentrations of local anesthetics are used, but not as great a risk with ultra-low doses, as the drug mass is insufficient to produce cardiorespiratory compromise. Total spinal may result from a relative drug overdose or from enhanced cephalad spread within the cerebrospinal fluid (CSF) due to issues involving baricity and maternal position. As an example, injection of a hyperbaric solution (relative to CSF) and placing the parturient in a steep Trendelenburg position or injection of a hypobaric solution and positioning the parturient in a seated position will result in exaggerated cephalad spread. Treatment of a high spinal may require intubation of the trachea to maintain adequate ventilation and protect the lungs from aspiration. The use of supportive care with assisted ventilation and 100 percent oxygen is often sufficient until the small amount of local anesthetic that migrated cephalad dissipates. The cardiovascular system must be supported with vasopressors and inotropes as necessary to maintain blood pressure. HYPOTENSION — Hypotension is a common side effect of local anesthetics administered into the neuraxis [6]. It is caused by block of sympathetic nerves, dilation of vascular beds, and decrease of venous return. The precise definition of hypotension in this setting is controversial; criteria include a 20 percent reduction in mean arterial pressure from baseline, or a systolic blood pressure <100 mmHg. These criteria do not account for the pain of labor, which tends to increase baseline blood pressure; specific maternal conditions associated with elevated blood pressure, such as preeclampsia; or a parturient with a low baseline systolic pressure. Hypotension is considered clinically significant if it is associated with maternal symptoms such as lightheadedness and nausea and/or deterioration of the fetal heart rate, a sign of compromised uteroplacental perfusion. Maintenance of left uterine displacement to avoid aortocaval compression is an important maneuver to decrease the incidence of hypotension. (See "Maternal cardiovascular and hemodynamic adaptation to pregnancy", section on supine hypotensive syndrome). Symptomatic hypotension should be treated with small intravenous doses of ephedrine (5 mg) or phenylephrine (100 mcg) [7], and intravenous fluids. Prophylactic ephedrine has also been used successfully (see "Fetal bradycardia" below) [8,9]. These drugs have no adverse effects on uterine blood flow. Hypotension with current techniques of labor analgesia — The incidence of hypotension is related to the speed of onset of the neuraxial block. Epidural block with a high concentration of local anesthetic results in a significant incidence of hypotension. In one study, administration of 4 to 6 mL of 0.5 percent bupivacaine resulted in hypotension in 17 percent of parturients [10]. Another trial reported 12 mL of 0.25 percent bupivacaine caused hypotension in 20 percent of women [11]. However, the use of ultra-low dose local anesthetic techniques (eg, bupivacaine 0.04 percent) is associated with a lower incidence (9 percent) of hypotension [12]. This may be explained by the slow block onset that allows time for compensatory vasoconstriction to occur in unblocked regions. Prehydration prior to neuraxial anesthesia — The routine practice of intravenous hydration with crystalloid prior to initiation of epidural block has been questioned. The newer ultra-low dose "walking epidural" techniques are associated with a lower incidence of hypotension. As an example, one study of 95 normotensive women randomized to receive one liter of crystalloid or no preload prior to administration of epidural anesthesia found no difference in the frequency of hypotension between the two groups (6 and 10 percent, respectively) [13]. The concentration of bupivacaine administered was 0.1 or 0.2 percent, considerably higher than the 0.04 percent that we use in our "walking epidurals." In addition, a large intravascular fluid bolus may transiently inhibit uterine contractions [14]. Several techniques for avoiding maternal hypotension are described in detail separately. (See "Anesthesia for cesarean delivery", section on Avoidance of hypotension). Neuraxial opioids (except meperidine, which has local anesthetic effects) usually do not produce hypotension. Reports of hypotension after intrathecal opioid administration during active labor probably represent a relative decrease in blood pressure as a consequence of pain relief, and not a direct effect of the opioid [15]. A study in non-laboring parturients showed no decrease in blood
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pressure after intrathecal fentanyl 25 mcg [16] and another study showed that prehydration in not necessary in parturients receiving intrathecal fentanyl for labor analgesia [17]. FAILED BLOCK — A failed neuraxial block may be defined as inadequate analgesia/anesthesia following an epidural, spinal, or CSE. The precise incidence of failed block is unknown; it was 12 percent in one retrospective review [18]. Failed block may be caused by inadequate drug dosing, technical issues, or patient factors [19]. If the volume and/or concentration of administered analgesics/anesthetics are insufficient to adequately block the required spinal segments, pain relief will be incomplete. The dose of intrathecal anesthesia needed to obtain a satisfactory block for cesarean is independent of age, weight, height or body mass index [20]. Failed block may also be caused by impatience (eg, underestimating the latency of the administered drug and not allowing sufficient time to pass before declaring the block as failed). Operator or equipment related technical issues may also result in a failed block. As an example, if the epidural or spinal needle tip is not properly positioned, the injected drug will not be delivered to the desired location. If the aperture of the epidural or spinal needle is not wholly within the epidural or intrathecal space, respectively, a portion of the injected dose may not reach the intended site. With continuous epidural techniques, despite proper needle placement, the epidural catheter tip may not find its way into the epidural space, or may come to rest too far unilaterally, or protrude through an intervertebral foramen. These situations are more likely to occur if too great a length of catheter is threaded through the needle. More commonly, the catheter is initially inserted correctly within the epidural space, but later moves out of the space, toward the skin. Ideally, the length of epidural catheter inserted is sufficient to prevent inadvertent dislodgement, but not too great so as to minimize the likelihood of unilateral placement. In laboring patients, the optimal catheter length to insert into the epidural space appears to be 5 cm [21]. Other technical causes of failed block relate to patient anatomy (eg, post-surgical scarring that inhibits the spread of medication administered into the epidural space). Some unusual causes of failed spinal anesthesia have been described, and include rare anatomic malfomations such as dural ectasia, an abnormal ballooning of the thecal sac, and dural cyst. Injection of local anesthetic into an isolated area of the thecal sac may limit drug exposure to the target neural tissue [22]. Enlarged thecal volumes per se, even in the absence of dural ectasia or cysts, may cause dilution or poor distribution of the hyperbaric local anesthetic dose [23]. Failure of a block due to an inactive drug is possible, although very unlikely, particularly for amide-linked local anesthetics, which are very stable molecules. PRURITUS — Pruritus is a common side effect of neuraxial opioid administration. As an example, in one series, fentanyl (25 mcg) and bupivacaine (2 mg) were injected intrathecally, pruritus occurred in 100 percent of parturients, and 45 percent required treatment [24]. Pruritus does not occur after the administration of local anesthetics alone. The etiology appears to be modulation of nociceptive reception, not histamine release. Thus, treatment with an antihistamine such as diphenhydramine is not indicated, but is often used for its soporific effects. The ideal treatment for neuraxial opioid-induced pruritus is a small intravenous dose of an opioid antagonist such as naloxone (40 to 160 mcg) or the opioid agonist-antagonist nalbuphine (2.5 to 5 mg). Small doses of opioid antagonists are known to selectively reverse opioid side effects without affecting analgesia [25]. A common approach is to administer 40 to 80 mcg naloxone intravenously, and titrate additional small doses to effect. A single dose of naloxone sometimes prevents recurrent itching. Alternatively, the patient may be given intravenous patient-controlled analgesia (PCA) naloxone, to allow her to self-titrate 40 mcg every five minutes [26]. NAUSEA AND VOMITING — Nausea occurs commonly in laboring patients due to visceral pain. Epidural and spinal local anesthetic block effectively diminish or eliminate pain, but can also precipitate nausea and vomiting. The mechanism is a decrease in blood pressure causing hypoperfusion of the area postrema in the medulla or cephalad spread of opioids to the
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chemoreceptor trigger zone. The incidence of nausea and vomiting after neuraxial opioid is much greater with the relatively poorly lipid soluble morphine compared to more lipid soluble agents, such as sufentanil, because morphine tends to travel cephalad within the aqueous CSF. The optimal treatment for opioid-induced nausea is administration of an opioid antagonist such as naloxone or the opioid agonist-antagonist nalbuphine (see "Pruritus" above for dosing). Nausea and vomiting resulting from hypotension are treated by administration of vasopressors. RESPIRATORY DEPRESSION — Respiratory depression due to cephalad spread of opioids to brainstem respiratory centers after neuraxial block is a rare complication in laboring patients. Factors that increase the likelihood of respiratory depression include a large opioid dose, poor opioid lipid solubility (eg, morphine), and concomitant use of additional sedatives and opioids by other routes. Treatment is with a specific opioid antagonist, such as intravenous naloxone. The dose should be titrated to effect (40 to 80 mcg increments) and then an infusion of a dose sufficient to maintain an adequate respiratory rate should be instituted until the effect of the opioid has dissipated (eg, 1 to 2 mcg/kg/min) [27]. SPINAL HEADACHE — Spinal headache after neuraxial analgesia is due to leakage of CSF through a dural rent, traction on cranial structures, and cerebral vasodilation. The pathognomonic quality of this headache is its positional nature, worsened by sitting or standing and relieved by lying down. If the headache does not have this quality, other causes of headache should be sought. Incidence — The introduction of pencil point spinal needles has diminished the incidence of post dural puncture headache. In a randomized trial of 1000 patients comparing various types of cutting and pencil point needles, the incidence of headache was significantly lower with use of pencil point needles (headache with cutting needles: 5 to 8.7 percent versus headache with pencil point needles 2.8 to 4 percent) [28]. In particular, the incidence of severe headache (as indicated by the need for treatment with epidural blood patch) fell from 55 to 66 percent to 0 to 12.5 percent of headaches. A post-dural puncture headache is likely (approximately 80 percent) if the dura is punctured with an epidural needle, due to its large size (17 or 18 gauge). Fortunately, the incidence of accidental dural puncture with an epidural needle is relatively low for an experienced operator (approximately 1 to 2 percent). The high incidence (up to 80 percent) of headache after dural puncture with the epidural needle has prompted some practitioners to perform a prophylactic epidural blood patch (see below) after repositioning the epidural catheter at the end of labor and prior to its removal. In one trial in which women were randomly assigned to receive or not receive a prophylactic blood patch, there was no difference in the incidence of headache (56 percent in both groups), although women who received prophylactic patches had shorter median duration of symptoms [29]. Threading an epidural catheter into the intrathecal space and leaving it in situ for 24 hours has also been reported to reduce the incidence of headache [30,31], but the efficacy of this approach has not been established in randomized trials. If this is done and medication is injected into the catheter, it is important to remember that the catheter is now intrathecal, and no longer in an epidural location, so the dose of medication needs to be adjusted accordingly. Injection of a few milliliters of saline may produce immediate resolution of a headache, but the effects will be temporary [32]. Treatment — Epidural blood patch is the treatment of choice for severe, debilitating post dural puncture headache. An epidural blood patch is performed by injecting 10 to 20 mL of the patient's blood into the epidural space to form a clot over the dural defect. The clot prevents leakage of CSF while the dura heals. Conservative management with symptomatic therapy (eg, oral analgesics, caffeine) may be indicated if the patient does not desire epidural blood patch or if the headache is not severe. Most headaches will resolve in 7 to 10 days if untreated. (See "Post-lumbar puncture headache", section on Treatment). BACKACHE — In 1990, a retrospective study of 11,701 women found that long-term backache occurred after delivery more frequently in women who had an epidural during labor than in women
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who did not have one (19 versus 11 percent), and concluded there was a causal relationship between epidurals and backache [33]. Subsequently, a series of prospective studies by these authors and others found NO correlation between epidural labor analgesia and an increased incidence of long-term backache [34-40]. MATERNAL TEMPERATURE ELEVATION — Randomized trials and observational studies have observed a frequent and significant association between the use of epidural analgesia and rise in maternal temperature [41-49]. The etiology of the temperature increase is not clear, but may be related to reduced heat loss in women receiving epidurals since they have less pain-induced hyperventilation and less perspiration because of sympathetic block. Another explanation is that both epidurals and increased maternal temperature share risk factors such as nulliparity, induction of labor, internal monitoring, more vaginal examinations, longer labor, and longer duration of rupture of membranes, which are also risk factors for intraamniotic infection. Noninfectious inflammation and an abnormality in maternal thermoregulation are other possible causes [50]. Administration of acetaminophen does not prevent the maternal temperature elevation [51]. Data from an historical cohort study of maternal temperature before and after availability of epidural analgesia suggest that the epidural itself is the cause of the increased maternal temperature. When epidural usage increased from 1 to 83 percent, the incidence of maternal temperature greater than 100.4 degrees F also increased from 0.6 to 11 percent [43]. The rise in maternal temperature correlates with the duration of epidural analgesia [52,53]. In one study, there was no discernible effect during the initial four to five hours, but thereafter maternal temperature increased approximately 0.10 degrees C per hour [53]. This may explain why epidural-related fever is more common in nulliparas than multiparas since the latter tend to have shorter labors [47]. The presence of an elevated temperature may be misinterpreted as a sign of infection, since intrapartum fever is the most objective clinical sign of intraamniotic infection. Prompt antibiotic administration and diagnostic work-up may be instituted. The increase in maternal temperature associated with epidural analgesia has been implicated as the cause of an increased rate of neonatal sepsis investigations and morbidity, but is not associated with an increased rate of proven neonatal sepsis [54]. In a retrospective analysis, only four of 416 neonates evaluated were found to be septic, raising questions regarding the clinical criteria used to trigger such evaluations [44]. The decision to perform a neonatal septic work-up must be guided by factors in addition to maternal temperature. Triggers for septic work-up in neonates include low birth weight, prematurity, hypothermia at birth, maternal group B beta-hemolytic streptococcal colonization, preeclampsia, and maternal hypertension [55]. Prior to initiating antibiotic therapy, the clinician should consider whether there was prolonged use of epidural analgesia. Maternal shivering that occurs before the fever developed and a rapid fall in temperature after the epidural is discontinued suggest a noninfectious etiology [56]. URINARY RETENTION — Some women who have a neuraxial anesthetic may not be able to sense when their bladder is full and may not be able to void spontaneously [57]. Catheterization is indicated in these women. SPINAL/EPIDURAL HEMATOMA — Hemorrhage into the neuraxis, an unusual complication of spinal and epidural techniques, may occur if a vascular structure is punctured by a needle and/or catheter. Hematoma is less likely with a single-shot spinal technique, due to the relatively small size of the spinal needle [58] and the lack of an indwelling catheter. Accumulation of even a small quantity of blood may compress neural structures and produce ischemia because the spinal space is nonexpandable. Neural ischemia results in loss of sensory, motor, and bladder and bowel function; severe pain is not a common finding. The appropriate treatment is prompt surgical intervention, usually a laminectomy, and evacuation of the blood. Timely decompression of the hematoma is essential to avoid permanent loss of neurologic function. In one study, as an example, good outcomes were obtained in 50 percent of patients when surgery was performed within eight hours of diagnosis [58]. The diagnosis of
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spinal/epidural hematoma is complicated by the concealed nature of the bleeding, thus a high index of suspicion must be maintained. Since low-dose techniques for labor analgesia produce minimal motor block, their use permits continuous monitoring of lower extremity function in patients at risk for development of neuraxial hematoma. Neuraxial analgesia and the anticoagulated patient — Pregnant women may be treated with anticoagulants for a variety of indications. The most common indication for anticoagulation is the presence of a thrombophilia such as factor V Leiden mutation, prothrombin gene mutation, antithrombin deficiency, protein C deficiency, or protein S deficiency. The risk of hemorrhage into the neuraxis is increased in anticoagulated patients, thus one must consider the type of anticoagulant used, the dose, and the timing of its administration. For all patients in whom a bleeding tendency is suspected, an evaluation of coagulation status is indicated prior to neuraxial analgesia. (See "Anticoagulation during pregnancy"). The recommendations below are based on the Second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation [59]. The use of aspirin should not influence the decision to place a neuraxial block. Clopidrogel has been associated with several case reports of epidural hematomas. The American Society of Regional Anesthesia and Pain Medicine (ASRA) currently recommends a waiting period of 14 days between the last dose of ticlopidine and 7 days after the last dose of clopidrogel and the placement of a neuraxial block. Anticoagulation regimens, such as mini-dose aspirin and low-dose subcutaneous heparin (5000 units every 12 hours) are NOT associated with increased risk of spinal/epidural hematoma and do not need to be halted prior to spinal or epidural analgesia. Standard unfractionated intravenous heparin therapy is usually discontinued with the onset of labor. Subcutaneous heparin therapy is stopped 24 hours prior to a planned induction or cesarean section or with the onset of spontaneous labor. Neuraxial anesthesia may be administered when the partial thromboplastin time returns to normal. If anticoagulation with standard intravenous heparin is required in patients who have recently had epidural catheterization, heparin should not be given for at least one hour after the epidural catheter has been inserted or removed. In patients receiving intravenous heparin, the epidural catheter may be removed two to four hours after the last heparin dose, after the patient's coagulation status has been evaluated. Since heparin-induced thrombocytopenia may occur, patients receiving heparin for more than four days should have a platelet count assessed prior to neuraxial block and catheter removal. Low molecular weight heparin — Many disorders are currently being treated with fractionated low molecular weight heparin (LMWH). This therapy presents particular challenges because standard laboratory tests cannot be used to assess its activity. Many cases of spinal hematoma have been reported among nonpregnant patients receiving neuraxial analgesia in the presence of LMWH [60], some of whom had received other anticoagulant medications. Neuraxial blocks should not be performed until at least 12 hours after the last dose of low dose (prophylactic) LMWH (eg, enoxaparin 40 mg), and not until at least 24 hours after the last dose in patients receiving high-dose (therapeutic) LMWH (eg, enoxaparin 1 to 1.5 mg/kg every 12 hours). In addition: If postoperative LMWH is to be used, the first dose should not be administered prior to 24 hours postoperatively if a twice-daily dosing regimen is planned, and not prior to six to eight hours postoperatively if a single-daily dosing regimen is planned. For the twice-daily dosing regimen, epidural catheters should not be left in place. For the single-daily dosing regimen, epidural catheters may be maintained, but the catheter should not be removed
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for at least 10 to 12 hours after the last LMWH dose. In cases where blood is noted during the insertion of the spinal or epidural needle or catheter, even if the single daily dosing regimen is planned, LMWH should not be administered for the first 24 hours postoperatively. For both twice-daily and single-daily dosing regimens, if the patient has an indwelling epidural catheter postoperatively (eg, for postoperative analgesia), the LMWH should not be initiated until at least two hours after catheter removal. If LMWH prophylaxis must be instituted in the presence of an indwelling catheter, low-dose epidural techniques should be used to permit careful monitoring of neurologic function. Concomitant administration of antiplatelet medications or other anticoagulants in patients receiving LMWH may increase the risk of neuraxial hematoma. Warfarin — Neuraxial blocks should not be performed until laboratory tests of coagulation (prothrombin time, International normalized ratio [INR]) are normal in patients receiving oral anticoagulants (warfarin). Patients receiving therapy with a combination of anticoagulants are at particular risk of developing spinal/epidural hematoma. Neuraxial analgesia and low platelets — Thrombocytopenia (platelet count <150,000/microL) occurs in approximately 7 percent of pregnancies [61]. Nearly all women with low platelet counts in the third trimester may be classified as having gestational thrombocytopenia, immune thrombocytopenic purpura (ITP), or thrombocytopenia related to severe preeclampsia or HELLP syndrome. Gestational thrombocytopenia is the most common etiology, ITP occurs much less frequently. An important difference between ITP and gestational thrombocytopenia is that ITP may be associated with severe neonatal thrombocytopenia. However, with regard to the mother, neither gestational thrombocytopenia nor ITP is associated with a rapid decline in platelet count. This contrasts with hypertensive thrombocytopenia, which may accompany severe preeclampsia or the HELLP syndrome. In hypertensive thrombocytopenia, the platelet count may decline precipitously, and the platelet function may be abnormal as well. With gestational thrombocytopenia and ITP, platelet function is usually normal. (See "Thrombocytopenia in pregnancy"). An insufficient platelet number or deficient platelet function predispose to an increased risk of spinal/epidural hematoma upon neuraxial instrumentation. The precise platelet count needed to safely perform neuraxial analgesia is unknown. Currently, practitioners routinely perform neuraxial analgesia with platelet counts below 100,000/microL, although few will instrument the spinal/epidural space if the platelet count is below 50,000/microL. It is not necessary to routinely obtain a platelet count before administration of regional anesthesia in uncomplicated parturients [62]. When determining whether it is safe to instrument the epidural or intrathecal space in women with thrombocytopenia, the rate of decline of the platelet count is much more important than the absolute platelet number. The platelet count should be assessed prior to performing a neuraxial block, and compared to previous counts. As an example, a relatively low but stable platelet count of 55,000/microL likely presents less of a problem than a platelet count of 60,000/microL that had been 95,000/microL three to four hours previously. A compelling report from the pediatric oncology literature showed that spinal hematoma did not occur with lumbar puncture even with very low platelet counts [63]. In that study, 742 patients had platelet counts of 21,000 to 50,000/microL, 170 had platelet counts of 11,000 to 20,000/microL, and 29 had platelet counts <10,000/microL. Adequacy of platelet function must also be considered, but the laboratory tests needed to assess platelet function are not readily available on an emergency basis. The clinician often must assess the integrity of the coagulation system with a careful history and a physical examination focusing on the presence of petechiae, ecchymoses, or obvious oozing from intravenous catheter sites. (See "Preoperative assessment of hemostasis"). Neuraxial anesthesia has been utilized in patients with platelet counts around 70,000/microL, and
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without evidence of bleeding [61]. The etiology of the thrombocytopenia, the trend in the platelet number, and the history and physical examination are more important than the absolute platelet count per se. In addition, it may be reasonable to perform a spinal anesthetic with a platelet count under 70,000/microL if there is a compelling indication to do so based on a risk-benefit analysis [64]. A spinal technique is less traumatic than an epidural, and is preferred once the platelet count is under 70,000/microL. Soft, flexible catheters are preferred for an epidural technique, as they have a lower incidence of venous cannulation. When determining whether it is safe to instrument the epidural or intrathecal space in women with thrombocytopenia, the rate of decline of the platelet count is much more important than the absolute platelet number. The platelet count should be assessed prior to performing a neuraxial block, and compared to previous counts. As an example, a relatively low but stable platelet count of 55,000/microL likely presents less of a problem than a platelet count of 60,000/microL that had been 95,000/microL 24 hours previously. INFECTION — Aseptic technique is important to minimize risk of infection [65]. Epidural abscess or meningitis are uncommon complications of neuraxial block. Epidural abscess is more likely to occur after epidural techniques, whereas meningitis typically occurs after the dura has been punctured, either intentionally as part of a spinal anesthetic, or unintentionally as a complication of an epidural procedure. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on Spinal headache). A meta-analysis of reports published between 1990 and 2005 identified the incidence of "deep epidural infection" in obstetric patients as 1 in 145,000 [66]. A review of postdural puncture bacterial meningitis found 179 reported cases from 1950 to 2005 [67]. The most commonly isolated bacteria were mouth commensals. Presumably, droplet contamination from medical personnel was the source of the CSF infection, which argues for a mandatory policy of wearing masks during instrumentation of the neuraxis. Postdural puncture meningitis may be more common than appreciated, with an incidence as great as 1:50,000 to 1:10,000 [68]. Skin bacteria may also be introduced into the neuraxis during instrumentation, emphasizing the importance of meticulous skin cleansing prior to the procedure. Providone iodine is most commonly used for this purpose in the United States. Although chlorhexidine is a superior agent for skin decontamination, it is not currently approved for neuraxial block skin preparation by the US Food and Drug Administration because of concerns about potential neurotoxicity. PNEUMOCEPHALUS — Introduction of air into the CSF during placement of neuraxial block may result in acute onset of severe headache and other neurologic signs and symptoms [69]. This relatively rare complication may occur when air, rather than saline, is used to identify the epidural space with the loss-of-resistance technique. If the dura is inadvertently punctured, air may be injected into the CSF. If the parturient is sitting, the onset of headache and other neurologic symptoms may occur within a few seconds, as the air rapidly ascends to the brain, where it exerts its irritating effects. Use of saline rather than air for the loss-of-resistance technique can minimize the likelihood of this complication. FETAL EFFECTS — Maternal hypotension resulting from local anesthetic-induced sympathetic block may reduce placental perfusion. The placental bed is not autoregulated and, therefore, its perfusion is entirely dependent upon maternal systolic blood pressure. A decrease in perfusion pressure will result in decreased fetal oxygenation, which is manifested by deterioration in the fetal heart rate pattern (eg, bradycardia, repetitive late decelerations). However, in the absence of hypotension, epidural local anesthetics have been shown to improve intervillous blood flow [70], to have minimal effect on uterine or fetal umbilical vasculature as assessed by Doppler velocimetry [71], and to be associated with improved neonatal acid-base status [72]. A relatively large dose of opioid is required when administered as the sole agent for labor analgesia by the epidural route. Neuraxial opioids may affect the fetus and/or neonate by gaining access to the maternal circulation and undergoing transplacental passage as the plasma kinetics following injection
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of epidural morphine are similar to those seen after an intramuscular injection [73]. In one study, as an example, a dose of 5 mg epidural morphine produced substantial fetal and maternal plasma levels [74]. The small doses of opioid used for intrathecal administration are generally safe for the fetus. However, fetal bradycardia may be precipitated by intrathecal administration of opioid. Although the mechanism is not yet defined, the incidence is nearly twice as high that after epidural opioid administration [75]. Fetal bradycardia — A nonreassuring fetal heart rate after induction of neuraxial anesthesia may be due to maternal hypotension or uterine hyperactivity [8]. The administration of opioids intrathecally may induce a tetanic uterine contraction leading to fetal bradycardia [76]. A meta-analysis of nine trials reported fetal bradycardia within one hour of intrathecal opioid administration occurred in 39 of 535 (7.3 percent) patients versus 19 of 392 (4.8 percent) controls (RR 1.81, 95% CI 1.04-3.14) [75]. Despite a higher risk of fetal heart rate abnormality, the rate of cesarean delivery was not increased in women receiving intrathecal opioids. One proposed explanation is that the fetal bradycardia is due to intrathecal opioid-induced uterine tetany. The tetany is postulated to be due to rapid onset of analgesia, which causes a sudden decrease in plasma epinephrine and subsequent withdrawal of epinephrine's beta-sympathomimetic relaxant effects on the myometrium [77]. Uterine tetany may be reversed with one or two doses of intravenous nitroglycerin (60 to 90 mcg) [78]. The hypotension that predictably results is treated with ephedrine (5 to 10 mg) or phenylephrine (40 to 800 mcg). Persistent hypertonus can be treated with another dose of nitroglycerin or a beta agonist, such as terbutaline 0.25 mg intravenously; however, terbutaline results in a longer period of uterine relaxation and maternal tachycardia. Prophylactic administration of ephedrine to prevent maternal hypotension and fetal bradycardia has also been studied: A randomized trial showed that prophylactic administration of ephedrine (10 mg injected intravenously followed by a continuous drip of 20 mg over one hour) at the time of epidural initiation reduced the frequency of fetal heart rate changes within 40 minutes of anesthetic administration [8]. Fetal heart rate changes occurred in 2 of 72 treated patients versus 11 of 73 controls who did not receive prophylactic ephedrine upon initiation of their epidurals. Seven patients would need to be treated to prevent one case of abnormal fetal heart rate tracing. In another randomized trial, a single intramuscular dose of ephedrine (25 mg) or placebo was administered to 100 parturients immediately prior to receiving combined spinal epidural analgesia [9]. Significantly fewer women in the ephedrine group developed hypotension (10/50 versus 34/50 in controls), but they were more likely to develop fetal tachycardia than controls. There were no significant differences in the prevalence of fetal heart rate decelerations during the hour after the analgesia was administered (variable, late, prolonged) between the two groups. Prophylactic administration of ephedrine may be appropriate in patients who will be receiving relatively high concentrations of local anesthetics (eg, for cesarean), but is not necessary for those receiving walking epidural techniques with low concentrations of local anesthetics or opioids. Continuous infusion of ephedrine is not recommended because it has been associated with fetal acidosis in patients undergoing elective cesarean delivery under spinal anesthesia [79]. We infrequently use combined spinal-epidural for laboring patients to avoid potential complications, such as maternal hypotension and fetal heart rate abnormalities. Some prefer the low-dose "walking epidural," which takes effect relatively slowly and therefore is less likely to cause these problems. NEONATAL EFFECTS — An early study found that neonates of mothers who received epidural
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analgesia with local anesthetics had lower scores as assessed by the Early Neonatal Neurobehavioral Scale (EENS) than neonates of mothers who received no analgesia [80]. A subsequent study using the EENS found no difference in scores in neonates of mothers who had received epidural analgesia with bupivacaine, 2-chloroprocaine, lidocaine, or no analgesia [81]. Other studies of neurobehavior in neonates of mothers receiving epidural analgesia or systemic opioid analgesia have shown either no difference [82] or improved scores in neonates of mothers receiving epidurals [83]. By comparison, a meta-analysis reported neonates of mothers receiving epidural analgesia were more alert than those of mothers who received systemic opioids or no medication [84]. The cumulative effect of opioids delivered as part of continuous epidural infusions is another concern. This may result in a potentially significant total opioid dose over time. However, neurobehavioral assessment of neonates using the Neurologic and Adaptive Capacity Score (NACS) has not shown perceptible changes after prolonged epidural infusions of sufentanil [85] or fentanyl [86]. Breastfeeding — There is no definitive evidence that epidural analgesia interferes with breastfeeding success. One observational study of 171 postpartum women found that epidural labor analgesia with local anesthetics and opioids did not impede breastfeeding success when assessed at six to eight weeks after delivery [87]. A subsequent randomized, prospective trial examined the effect of fentanyl given epidurally during labor on breastfeeding [88]. Women received either 0, <150, or >150 mcg of fentanyl during labor. At 24 hours postpartum, there were no differences between the groups with regard to breastfeeding difficulties. However, at six weeks postpartum, significantly fewer women who received more than 150 mcg fentanyl in the epidural during labor were still breastfeeding. These results should be interpreted with caution due to methodological concerns, and lack of an obvious physiologic or pharmacologic mechanism by which the fentanyl might influence the incidence of breastfeeding six weeks after delivery [89]. The American College of Obstetricians and Gynecologists concluded that breastfeeding is not affected by choice of anesthetic; thus the choice should be based upon other considerations [62]. AREAS OF CONTROVERSY — There is considerable controversy concerning the non-analgesic effects of neuraxial pain relief. As an example, two meta-analyses have come to different conclusions about the effects of epidural anesthesia on length of the first stage of labor, cesarean delivery rate, breastfeeding success, and postpartum urinary problems (show table 1) [6,90]. One group reported data on these variables were inconclusive [90] while the other concluded that epidural anesthesia had no effect on the first three variables but may transiently increase postpartum urinary incontinence [6]. A critique of these two meta-analyses, which were performed in parallel and at the request of an invitational symposium, was published in the same journal as the analyses [91]. Effect of neuraxial analgesia on the progress and outcome of labor — A longstanding perception holds that neuraxial analgesia tends to slow labor and result in increased rates of instrumental and cesarean delivery. These attitudes are currently under intense scrutiny. A meta-analysis of 20 trials concluded epidural analgesia did not significantly increase the risk of cesarean delivery (RR 1.07, 95% CI 0.93 to 1.23); however, it was associated with an increased risk of instrumental vaginal birth (RR 1.38, 95% CI 1.24 to 1.53) [92]. The reason for the increased frequency of instrumental delivery in patients with epidural analgesia is unclear. One possible explanation is that the presence of epidural analgesia prompts a difference in obstetric management of the second stage of labor. In one study, as an example, there were significantly more instrumental deliveries in patients with epidurals when residents were allowed to use elective outlet forceps or vacuum [93]. It may be that the presence of effective pelvic analgesia encourages the use of instrumental delivery. The concentration of local anesthetics used for the epidural may affect the incidence of instrumental delivery. The concentration of local anesthetic used with current epidural techniques is, in some cases, 1/10th of the strength that was used in the past. Newer low-dose techniques, by achieving sensory block while preserving motor strength, have been shown to promote spontaneous vaginal delivery (or decrease the rate of instrumental delivery). For example, a study of low-dose techniques
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randomly assigned 1054 nulliparous women requesting epidural pain relief to traditional (intermittent 10 mL boluses of 0.25 percent bupivacaine), low-dose combined spinal epidural (bupivacaine 2.5 mg and fentanyl 25 mcg, followed by a 15 mL bolus of 0.1 percent bupivacaine and 2 mcg/mL fentanyl when the spinal component wears off with intermittent 10 ml boluses of this combination of drugs), or low-dose infusion epidural (bolus of 15 mL 0.1 percent bupivacaine and 2 mcg/mL fentanyl followed by an infusion of 10 mL/hr of same) [94]. The spontaneous vaginal delivery (SVD) rates in the three groups were 35, 43, and 43 percent, respectively. The higher SVD rate among women receiving low-dose techniques was entirely accounted for by a reduction in the number of instrumental vaginal deliveries; the cesarean delivery rate was 28 to 29 percent in all three groups. Therefore, low-dose techniques should be recommended over traditional epidural administration to reduce the rate of operative vaginal delivery [95]. The following examples illustrate findings from several studies: One randomized study of 318 nulliparous women examined the rate of cesarean delivery in patients receiving systemic opioids versus those administered epidurals (using an intentto-treat analysis) [96]. There was no significant difference in cesarean delivery rate between groups (approximately 14 and 10 percent, respectively) [96]. Similar findings were noted in a trial that randomly assigned 459 nulliparous women to receive either epidural analgesia or intravenous meperidine analgesia via a patient controlled pump [45]. The cesarean delivery rate was equivalent for the two groups, 7 and 9 percent, respectively, with protocol violations in 8 percent. Another retrospective analysis of 18,333 deliveries reported that obstetric practice style, but not epidural use, correlated with the cesarean delivery rate [97]. Although there is an association between epidural use and the cesarean delivery rate (observational studies report a more than four-fold increased risk of cesarean and instrumental deliveries), there is no causative link. One review reported that epidural analgesia doubled the risk of oxytocin augmentation, but did not increase the risk of cesarean delivery either overall or for dystocia, nor did it significantly increase the risk of instrumental vaginal delivery in clinical trials [98]. The authors concluded that low-dose epidural analgesia may increase the risk of oxytocin augmentation, but not of cesarean delivery, and although most studies showed a longer labor among women with epidural analgesia than without it, most used inappropriate statistical analysis (see "Timing of epidural administration" below). Pain as a marker of dysfunctional labor — A potential confounding variable of all studies examining the effect of regional analgesia on the progress and outcome of labor is that pain itself may be predictive of dysfunctional labor and an increased likelihood of instrumental or operative delivery [99]. This is important because patients with severe pain and protracted, dysfunctional labors are more likely to request or receive epidural or spinal analgesia. Thus, it may be falsely concluded that neuraxial techniques are causally related to poor labor outcomes, whereas the relationship may simply be an associative one. As an example, one study found that patients who experienced pain and distress very early (during the latent phase of labor) had prolonged labor and high rates of instrumental and cesarean delivery compared to patients who experienced mild pain with which they were able to cope [100]. Future studies need to account for this potential confounder. Potential benefits of delayed pushing — Obstetric practice in the United States often dictates that the parturient begin pushing when the cervix attains full dilation (10 cm). However, randomized prospective studies have questioned this practice and suggested delaying pushing until the presenting fetal part descends [101-104]. As an example, a large (n =1862) randomized multicenter study documented that delayed pushing was an effective means of reducing difficult deliveries in nulliparous women (relative risk 0.79; 95 percent CI 0.66 to 0.95) [102]. The greatest effect was on midpelvic procedures (relative risk 0.72; 95 percent CI 0.55 to 0.93). Delayed pushing predictably increased the duration of the second stage (by 54 minutes), and resulted in lower umbilical cord blood pH, but no difference was detected in overall neonatal morbidity. If delayed pushing is an effective means of
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reducing instrumental delivery rates, effective epidural analgesia that preserves muscle strength will be of great assistance. Similar findings were reported in a meta-analysis that included this study [104]. Timing of epidural administration — An American College of Obstetricians and Gynecologists Committee Opinion concluded that "maternal request is sufficient medical indication for pain relief during labor" and that neuraxial anesthesia does not increase the frequency of cesarean delivery [105]. Although some obstetricians have advocated withholding epidural analgesia until a significant cervical dilation, most commonly 4 to 5 cm, has been achieved, there are no data to support this practice. The best data on the safety of early epidural comes from two large randomized trials that showed that the cesarean delivery rate was not increased when neuraxial analgesia was given in early labor and early administration of neuraxial analgesia was associated with a significant decrease in time to full dilatation [106,107]. The first trial included 750 nulliparous women at term, in spontaneous labor or with spontaneous rupture of membranes, and with cervical dilatation less than 4 cm (mean 2 cm) who were randomly assigned to receive intrathecal fentanyl plus epidural bupivacaine and epinephrine or parenteral hydromorphone at their first request for analgesia [106]. Women in the intrathecal group received epidural analgesia upon request throughout labor. Women in the parenteral group continued to receive parenteral analgesia at the second request for analgesia if their cervix was less than 4 cm, but received epidural analgesia if their cervix was ≼4 cm. Major findings from this trial were: - Early administration of neuraxial analgesia did not increase the rates of cesarean delivery or instrumental delivery, which were similar in both groups (cesarean 17.8 and 20.7 percent, instrumental 19.6 and 16 percent). - Early administration of neuraxial analgesia was associated with significant decreases in times to full dilatation and vaginal delivery compared to women who received parenteral analgesia (time to full dilatation 295 versus 385 minutes, time to vaginal delivery 398 versus 479 minutes). - Pain scores after first administration of analgesia were significantly lower in the neuraxial group (2 out of 10 versus 6 out of 10, where 0 is no pain and 10 is severe pain). Over 90 percent of patients in both groups received oxytocin, but the infusion was begun before the first request for analgesia in three-quarters. The second trial included 449 nulliparas at term in labor with cervical dilatation less than 3 cm who were randomly assigned to immediate epidural at first request for analgesia or delay in epidural placement until the dilatation of at least 4 cm [107]. The mean cervical dilatation in the two groups at epidural placement was 2.4 and 4.6 cm, respectively. As with the trial above, there were no significant differences in cesarean or instrumental delivery rates between groups (cesarean 13 and 11 percent, instrumental 17 and 19 percent), but the duration of the first stage was significantly shorter in the early epidural group. Thus, a reasonable approach is to allow the parturient to receive neuraxial analgesia when she desires it, as long as the diagnosis of labor has been established or a commitment to deliver has been made. It is also reasonable to insert an epidural catheter before pain is severe so that analgesics can be injected when the patient begins to experience discomfort. In particular, women should not be required to reach an arbitrary cervical dilation such as 4 to 5 cm before receiving epidural anesthesia. SUMMARY AND RECOMMENDATIONS Epidural and spinal anesthetic techniques provide optimal pain relief for parturients.
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Although generally quite safe, these techniques are also associated with various untoward effects. Side effects such as systemic local anesthetic toxicity or spinal headache are caused by technical factors and/or dosing, such as inadvertent intravenous injection or unrecognized dural puncture. Spinal hematoma is a rare complication, and is more likely in patients receiving anticoagulants. Meticulous attention to proper technique reduces the risk of these complications. Should they occur, prompt treatment is indicated. Other untoward effects are caused by known pharmacological effects of the analgesic medications, such as hypotension, pruritus, nausea and vomiting and respiratory depression. These side effects are optimally managed by administering small doses of an opioid antagonist. A variety of other side effects have been attributed to regional analgesic techniques, such as long-term backache, effects on the progress and outcome of labor and effects on breastfeeding success. Although an association between regional analgesia and these side effects may exist, a cause-and-effect relationship has not been established. The risk of potential unwanted effects must be weighed against the unparalleled pain relief these techniques provide.
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Hollmen, AI, Jouppila, R, Jouppila, P, et al. Effect of extradural analgesia using bupivacaine and 2-chloroprocaine on intervillous blood flow during normal labour. Br J Anaesth 1982; 54:837.
Hughes, AB, Devoe, LD, Wakefield, ML, Metheny, WP. The effects of epidural anesthesia on the Doppler velocimetry of umbilical and uterine arteries in normal term labor. Obstet Gynecol 1990; 75:809.
Reynolds, F, Sharma, SK, Seed, PT. Analgesia in labour and fetal acid-base balance: a meta-analysis comparing epidural with systemic opioid analgesia. BJOG 2002; 109:1344.
Bellanca, L, Latteri, MT, Latteri, S, et al. Plasma and CSF morphine concentrations after i.m. and epidural administration. Pharmacol Res Commun 1985; 17:189.
Nybell-Lindahl, G, Carlsson, C, Ingemarsson, I,et al. Maternal and fetal concentrations of morphine after epidural administration during labor. Am J Obstet Gynecol 1981; 139:20.
Mardirosoff, C, Dumont, L, Boulvain, M, Tramer, MR. Fetal bradycardia due to intrathecal opioids for labour analgesia: a systematic review. BJOG 2002; 109:274.
Clarke, VT, Smiley, RM, Finster, M. Uterine hyperactivity after intrathecal injection of fentanyl for analgesia during labor: a cause of fetal bradycardia?. Anesthesiology 1994; 81:1083.
Cascio, M, Pygon, B, Bernett, C, Ramanathan, S. Labour analgesia with intrathecal fentanyl decreases maternal stress. Can J Anaesth 1997; 44:605.
Mercier, FJ, Dounas, M, Bouaziz, H, et al. Intravenous nitroglycerin to relieve intrapartum fetal distress related to uterine hyperactivity: a prospective observational study. Anesth Analg 1997; 84:1117.
Cooper, DW, Carpenter, M, Mowbray, P, et al. Fetal and maternal effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Anesthesiology 2002; 97:1582.
Scanlon, JW, Brown, WU, Weiss, JB, Alper, MH. Neurobehavioral responses of newborn infants after maternal epidural anesthesia. Anesthesiology 1974; 40:121.
Abboud, TK, Khoo, SS, Miller, F, et al. Maternal, fetal, and neonatal responses after epidural anesthesia with bupivacaine, 2-chloroprocaine, or lidocaine. Anesth Analg 1982; 61:638.
Thorp, JA, Hu, DH, Albin, RM, et al. The effect of intrapartum epidural analgesia on nulliparouslabor: a randomized, controlled, prospective trial. Am J Obstet Gynecol 1993; 169:851.
Dailey, PA, Baysinger, CL, Levinson, G, Shnider, SM. Neurobehavioral testing of the newborn infant. Effects of obstetric anesthesia. Clin Perinatol 1982; 9:191.
Halpern, SH, Leighton, BL, Ohlsson, A, et al. Effect of epidural vs parenteral opioid analgesia on the progress of labor: a meta-analysis. JAMA 1998; 280:2105.
Loftus, JR, Hill, H, Cohen, SE. Placental transfer and neonatal effects of epidural sufentanil and fentanyl administered with bupivacaine during labor. Anesthesiology 1995; 83:300.
Porter, J, Bonello, E, Reynolds, F. Effect of epidural fentanyl on neonatal respiration. Anesthesiology 1998; 89:79.
Halpern, SH, Levine, T, Wilson, DB, et al. Effect of labor analgesia on breastfeeding success. Birth 1999; 26:83.
Beilin, Y, Bodian, CA, Weiser, J, et al. Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study. Anesthesiology 2005; 103:1211.
Halpern, SH, Ioscovich, A. Epidural analgesia and breast-feeding. Anesthesiology 2005; 103:1111.
Lieberman, E, O'Donoghue, C. Unintended effects of epidural analgesia during labor: A systematic review. Am J Obstet Gynecol 2002; 186:S031.
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Thacker, SB, Stroup, DF. Methods and interpretation in systematic reviews: Commentary on twoparallel reviews of epidural analgesia during labor. Am J Obstet Gynecol 2002; 186:S078.
Anim-Somuah, M, Smyth, R, Howell, C. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev 2005; 19:CD00033.
Bofill, JA, Vincent, RD, Ross, EL, et al. Nulliparous active labor, epidural analgesia, and cesarean delivery for dystocia. Am J Obstet Gynecol 1997; 177:1465.
Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial. Lancet 2001; 358:19.
Thornton, JG, Capogna, G. Reducing likelihood of instrumental delivery with epidural anaesthesia. Lancet 2001; 358:2.
Clark, A, Carr, D, Loyd, G, et al. The influence of epidural analgesia on cesarean delivery rates: a randomized, prospective clinical trial. Am J Obstet Gynecol 1998; 179:1527.
Segal, S, Blatman, R, Doble, M, Datta, S. The influence of the obstetrician in the relationship between epidural analgesia and cesarean section for dystocia. Anesthesiology 1999; 91:90.
Zhang, J, Klebanoff, MA, DerSimonian, R. Epidural analgesia in association with duration of labor and mode of delivery: a quantitative review. Am J Obstet Gynecol 1999; 180:970.
Hess, PE, Pratt, SD, Soni, AK, et al. An association between severe labor pain and cesarean delivery. Anesth Analg 2000; 90:881.
Wuitchik, M, Bakal,D, Lipshitz, J. The clinical significance of pain and cognitive activity in latent labor. Obstet Gynecol 1989; 73:35.
Vause, S, Congdon, HM, Thornton, JG. Immediate and delayed pushing in the second stage of labour for nulliparous women with epidural analgesia: a randomised controlled trial. Br J Obstet Gynaecol 1998; 105:186.
Fraser, WD, Marcoux, S, Krauss, I, et al. Multicenter, randomized, controlled trial of delayed pushing for nulliparous women in the second stage of labor with continuous epidural analgesia. The PEOPLE (Pushing Early or Pushing Late with Epidural) Study Group. Am J Obstet Gynecol 2000; 182:1165.
Petrou, S, Coyle, D, Fraser, WD. Cost-effectiveness of a delayed pushing policy for patients with epidural anesthesia. The PEOPLE (Pushing Early or Pushing Late with Epidural) Study Group. Am J Obstet Gynecol 2000; 182:1158.
Roberts, CL, Torvaldsen, S, Cameron, CA, Olive, E. Delayed versus early pushing in women with epidural analgesia: a systematic review and meta-analysis. BJOG 2004; 111:1333.
ACOG Committee Opinion No. 339: Analgesia and Cesarean Delivery Rates. Obstet Gynecol 2006; 107:1487.
Wong, CA, Scavone, BM, Peaceman, AM, et al. The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med 2005; 352:655.
Ohel, G, Gonen, R, Vaida, S, et al. Early versus late initiation of epidural analgesia in labor: does it increase the risk of cesarean section? A randomized trial. Am J Obstet Gynecol 2006; 194:600.
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GRAPHICS Unintended effects of epidural anesthesia for labor pain results of two meta-analyses [1,2]
Variable Length of first stage of labor Length of second stage of labor Rate of instrumental vaginal delivery Cesarean delivery rate Intrapartum fever Successful breast-feeding at six weeks Urinary problems in early postpartum period
Conclusions of meta-analysis No difference [1], possibly increased [2] Increased [1,2] Increased [1,2] No difference [1], possibly increased [2] Increased [1,2] No difference [1], insufficient data [2] Increased [1], insufficient data [2]
1. Leighton, BL, Halpern, SH. The effects of epidural analgesia on labor, maternal, and neonatal outcomes: A systematic review. Am J Obstet Gynecol 2002; 186:S069. 2. Lieberman, E, O'Donoghue, C. Unintended effects of epidural analgesia during labor: A systematic review. Am J Obstet Gynecol 2002; 186:S031.
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text:
EU Delays Ban on Imported CO2 Credits by Four Months
The European Union decided to ban the import of carbon credits linked to certain industrial gases as of May 2013, delaying by four months the starting date for the curbs in the world's largest greenhouse-gas market.
The agreement by the EU's 27 national governments targets energy and manufacturing companies' use of United Nations-sponsored offsets linked to hydrofluorocarbon-23 and some nitrous oxide credits. The decision to push back the Jan. 1, 2013 date proposed by the European Commission, the EU's regulatory arm, widened the discount of March 2013 offsets.
The EU said the credits facing the ban, generated for reducing emissions of the industrial gases, offer "exorbitant" return rates, can create a "perverse incentive" for investors and undermine the market's integrity.
"Our aim is not to reduce the number of credits available but to ensure the international carbon market is based on a better quality and distribution of credits," European Climate Commissioner Connie Hedegaard said in a statement published today in Brussels.
More than 11,000 power plants and factories in the EU carbon system may use UN credits as a cheaper way to comply with their pollution quotas. Regulators around the world are clamping down on HFC-23, whose warming potential is 11,700 times more powerful than carbon dioxide. Officials at the UN carbon market in November called for a revision of its procedures.
Surrendering Allowances
The EU emissions-trading program, known as ETS, is a cornerstone of European efforts to tackle the heat waves, storms and floods tied to climate change. The current five-year phase in the system ends in 2012 and the deadline for surrendering allowances for that year is the end of April 2013.
The delay of the ban is in line with calls by the International Emissions Trading Association, which urged the commission and the EU governments to delay the starting date to May 1, 2013.
Some companies in the European cap-and-trade system, including Italy's biggest utility, Enel SpA, called on the regulator to limit the scope and delay the start of the ban.
"The agreement means that any UN credits issued between January 2013 and the end of April 2013 can still be used for 2012 compliance," Peter Zapfel, head of policy coordination at the commission's climate department, said by phone. "The difference between the final date for compliance that we suggested and the one that was approved is -- according to different analyst estimates -- 30 million to 40 million credits more."
Parliamentary Scrutiny
The discount of UN carbon offsets for March 2013 against those for December 2012 widened by 5 cents to 14 euro cents as of 4:46 p.m. on London's ICE Futures Europe exchange.
The ban will apply to UN credits linked to HFC-23 and nitrous oxide from adipic acid production from the Clean Development Mechanism, the world's second-biggest CO2 market, and the Joint Implementation program. The measure will be subject to a three-month scrutiny by the European Parliament before it's officially adopted by the commission.
The 23 projects that cut HFC-23 and nitrous oxide from adipic acid production registered under the CDM account for two-thirds of all credits generated by the mechanism, according to the commission data. Most of them are located in China and other developing countries.
In the 2008-2012 trading period, emitters in the European program can swap as many as 1.6 billion UN credits with EU permits on a one-for-one basis. The EU average annual emissions cap for that period is 2.04 billion metric tons of carbon dioxide, valued at nearly 30 billion euros at today's prices. One permit represents one ton of CO2.
"Today´s vote marks an historic victory for environmental integrity over financial interests and puts the EU ETS back on the right track," said Natasha Hurley, EU policy adviser at environmental lobby group CDM Watch. "While we welcome the outcome of today´s vote, it's unfortunate that member states were not entirely immune to pressure from a small group of investors who lobbied hard to extract as many concessions as possible throughout this process."

subset: commoncrawl


text:
She did both.
"She let loose," her grandson, Matt Bach, said. "She took a shot and did the dance ... She was dancing out there saying, "I don't know what came over me, I don't know what came over me!' She was out there kicking it up with everyone."
Bayoff died Sunday, about two weeks shy of her 99th birthday.
"Baba," or "grandma" in Macedonian, as she was known by her family, was born in Bouf, Macedonia in 1912 -- a year which Bach said was the subject of one of her favorite jokes.
"When you asked her age, she would say, 'When the Titanic went down, I popped up!" Bach said.
Bayoff's father immigrated to the U.S. soon after she was born. Fifteen years later, after setting up a hotel and restaurant in Ann Arbor, Mich., Bayoff, her mother and brother made the journey to join her father. Her parents would later have three more children, Bach said.
Soon after arriving, the Great Depression struck and Bayoff took on helping to raise her younger siblings, said Bayoff's sister, Helen Velikoff.
"To me, she was like a second mother," Velikoff said. "My mother couldn't read or write or speak English -- (Bayoff) took over a lot of responsibility to raise us. She learned English and she worked in my father's business. If it wasn't for her -- we're talking Depression times --she gave us bicycles and dolls and candy and our first Christmas tree and first radio...she gave us a childhood."
She often used her love of knitting and crocheting to help others, sending gloves to soldiers during World War II and making traditional handkerchiefs for brides, Velikoff said.
"She was a giving person that way, if somebody needed something, they always turned to Flossie," she said.
Her handkerchiefs were known worldwide, Velikoff said, remembering a story her sister told her about two women from Australia who were sitting behind Bayoff in church, discussing "the woman here who makes those lace hankies." The women later asked Bayoff to make 18 hankies to take back to Australia.
In 1932, Bayoff married Spase Bayoff in Detroit. The couple moved to Flint and she took at job working for Flint Public Schools in the kitchen.
Then, when the Whiting opened in 1967, Bayoff took a job cleaning the auditorium.
"A lot of people looked at it and it's size and didn't want to work there, so she said, 'I'll do it,'" Bach said.
The job allowed her to meet entertainers like Grand Funk Railroad, who she teased about cutting their long hair.
When Lucille Ball's daughter, Lucie Arnaz, performed at the Whiting, the performer received a large bouquet of red roses, Bayoff's favorite, from the "I Love Lucy" star. After the show, Arnaz threw the roses away but Bayoff took them home and planted them in her yard, Bach said.
Bayoff loved flowers and, in addition to tending her garden, she also cared for her daughter's garden and St. Nicholas Orthodox Church's garden, where she was active in the congregation, Bach said.
Always independent, Bayoff lived on her own until last year, Velikoff said.
"If you tried to help her, she said, 'I can do it. Believe me, I can do it myself,'" she said.
A visitation will be held from 1 to 4 p.m. and from 6 to 8 p.m. on Wednesday at Swartz Funeral Home, 1225 West Hill Road. A funeral service will be held at 11:30 a.m. Thursday at St. Nicholas Orthodox Church, 2143 South Center Road, Burton. Visitation will be held on hour before the service.


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What appears to be a sinkhole is causing some unusual problems along a creek in York County.
Video: Click here to see the sinkhole
The sinkhole opened up under a culvert that carries Willis Run in West Manchester Township.
For unknown reasons, the ground under the culvert gave way, causing the water to flow into a deep hole.
The owners of a nearby Meineke business are worried where the water might be going.
"It is a 30-foot hole in the ground that is 50 yards from the building. We're hoping it is not going in the direction of the building," said Ben Ramsay, Meineke operator.
The township fenced off the area around the sinkhole. There is no word yet on when it will be repaired.


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Island Don
I am really interested in the Prius C, but the gas mileage of the Mitsu Mirage is not far behind. I plan to own the 2015 of one of these and plan to own for 250,000kms. Will the gas savings of the Prius C 2 off set the fully maxed Mirage? Does the quality of the Toyota come into play that much after 160kms to warrant the higher price? Which would you buy expecting to drive 8 8yrs and 250k???
I have 2012 Camry Hybrid as a taxi. Today while driving, the engine stopped running all of a sudden and check engine light came on. There was a message on the screen saying 'Check Hybrid System'. I get the car towed at the dealership and they said it is EGR Valve that needs to be replaced. I doubt it as there is only 99600 kms on my car and if the message says check hybrid system how can it be EGR Valve.
Please advise me on this.
Thank You
Motormouth.ca says:
gordon Skoog
What do you think about the new Smart Electric car coming next spring? Would it be a good runabout for around Vancouver for doing short everyday errands. I am retired have a 2010 Grand Caravan wheelchair ramp equipted for my wife, find myself running around town and it is terrible on gas and large to park in some spots, so I think a Smart Electric would be good. We also have a MB sprinter RV and it could tow the Smart Car on trips.
Sincerely Gordon Skoog
Motormouth.ca says:
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text:
Automation Is Our Friend
If you do it once, great. If you do it twice, frown. If you do it three times, automate it.
Even Unix adherents recognize how ugly and ill tempered their favorite child can be at times. But no matter how ugly Unix gets, it has a philosophy that makes all that ugliness worthwhile:
. Everyday tasks that you do over and over can be put into a script so that you can encapsulate the knowledge of how to do them, and invoke that knowledge with a single command.
is cryptic.
is amazingly cryptic.
is a world unto its own. Why put up with these and other Unix tools? Why do we want to live in a world where -s means something different from -S (and I have to remember which is which)? Because in this world I can automate routine tasks.
It would be nice if there were automatable tools that weren't quite so cryptic, though. If find, sed, and awk weren't so cumbersome, they probably would have made it into WideSpreadUse
amongst the masses.
-- Happily, you can use nice friendly languages like Python or Ruby as a replacement for unix shells and weird cryptic commands
If configuration files are text, then you can use built-in text manipulation tools to automate repeated processes. If configuration files are binary, then I'm at the mercy of the configuration program that knows how to manipulate them (it seldom being practical to write a tool for that one type of file). What manipulation of configuration files might you automate? Well, how about being able to use
to see what changed in the configuration file? How about using
to automatically change the stock configuration file to your favorite settings?
Are you using a GUI development environment that turns into a half-hour click-fest when you need to deploy? If there were command-line tools, you could automate it. Just start the script and go have coffee. Better yet, have a cron job start the script at night and send you email when it's done.
I personally like it when I've got a nice slick GUI tool for doing things interactively, coupled with an automatable interface such as a CLI. Give me the best of both worlds any day.
Oh, absolutely, yes. But why do so few GUI tool makers provide CLI tools?
Here's why: There is one best way to do it, and the GUI is it. Providing a CLI tool to do the same things you can do in the GUI would be an admission of personal failure: because GUIs are inherently better, a failure of
GUI to be better for something must mean I didn't do it right. Better not to provide the tool so I don't have to see the evidence of my failure.
Providing a CLI tool for tasks that need to be automated doesn't make the GUI any worse at what it does, but it openly admits that the GUI isn't the best tool for all tasks. We'd rather not admit that, so let's not provide a CLI tool.
The other reason is more practical, but not as fun to rant about: The traditional breeding grounds of GUI development tools provide much a weaker command-line environment than Unix, making CLI tools harder to work with. And yet that practical reason comes from the same mindset: Why do we need to provide a strong command-line environment when we've given you this superior GUI environment?
I would argue that the DOS command-line environment was weak long before Windows came along. :) That said, the vast majority of users (not programmers) don't really care too much for system-wide automation. At most, they're quite happy with being able to run a "Record" feature in their favorite GUI app and just maybe tinker with the resulting macro. Mind you, with the number of times I've seen people doing a MailMerge
by hand, it looks like they don't bother learning the automation they've already got. If a larger subsection of the market wanted automation, then they'd probably get it. (Note: automation != CLI by default. It's just that it's easier to automate on the command line in many cases)
But of course. The problem is, you don't miss what you never use, so how make the masses understand that they're throwing their effort down the waste basket by not automating?
I rather think the problem is that we humans have pitiful utility functions, especially regarding activities that are incidental to our main goal. This is why we fail to
. People really do start using automation once the 'price' of setting it up becomes close to the 'price' of one instance of the repeated activity.
I rarely tell my email client to check for mail. It was as easy to tell it 'check for mail every x minutes' as it was to tell it to 'check for mail'. Actually, it was easier, as that was a default setting
I had a vcr, but I never ever taped shows, it was just too much effort. I got a dvr, now recording shows is as easy as channel surfing, I record often.
OK, Mr. Vendor, you're going to provide a GUI (and no CLI), for all the obvious reasons. Please, please, please also provide an object model, accessible from external programs. Then I can still automate things. ...not nearly as easy, but possible. [Note: This is the
As usual, Apple had this solution first
For WindowsUsers
, if you've got a decent
in your program, it's reasonably easy to automate it using javascript in the Windows Scripting Host. [Reasonably easy, in this context, meaning no harder than learning Perl or BashScript
to do something like this in a CLI] Of course, most
s suck, and so do most
interfaces for MacUsers
A very simple example for applying the
to "Wiki navigating and editing": if in browse-mode you see a typo for correction, then mark the text to be corrected and activate your command. The script reads window.location, isolates the part behind "?", inserts "edit=", browses to the corresponding
page and positions the cursor appropriately for editing. (Of course a
would be much more comfortable in this case ;-). --
Is that simpler than just correcting the typo? Automation works best for things that can be done without much input from you. If the browser could find and correct typos automatically, that's great. But the bottleneck here is you noticing the typo, not the actual correction. If you make the correction easier then you are optimizing the non critical resource. --
The most critical resource is our life-time, so each saved keystroke counts as long as there is no better automatic replacement. Count the keystrokes to correct the following typo and see how much time is wasted in a non-
. -- fp
See also
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July 28, 2009
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text:
This weekend, you can get a taste of Muskegon food and a sample of Muskegon hockey.
Up and down Western Avenue, folks can take in the Fourth Annual Taste of Muskegon.
That's on Friday and Saturday.
For four days — Thursday through Sunday — area hockey fans can get their first taste of the United States Hockey League.
Three scrimmages on Thursday and Friday (5, 7 and 9 p.m.) and three on Saturday (8 a.m., 10 a.m. and noon) will showcase the talents of about 100 players on six teams.
What fans won't want to miss is the 8 p.m. all-star game on Saturday night or at 10 a.m. on Sunday. The best 40 players from the week will be split into two teams and they'll be going at it with a spot on the Muskegon Lumberjacks' roster at stake. There will be rosters with numbers available so players are easily identified.
The week began on Monday with 100 players attending the team's Open Camp.
On Thursday, the top players from the Open Camp will join players who have been drafted and signed by the Lumberjacks. Of the 36 players whose rights belong to the Jacks, 34 are expected to be here. One player who was drafted may opt to play in another junior league and one of the futures picks, who lives out of state, is not expected to be here. With the draft picks, plus the 45 players who have been invited, there could be about 20 players from Open Camp invited to stick around for the final four days of the camp. The final four days could be some "must" viewing for local hockey fans.
Those four days is when the tempo picks up to USHL standards. For those a bit skeptical about what is in store for this fall, or for those who view this as "high school hockey" or "kiddie" hockey, here is an opportunity to find out first-hand what the league is all about.
You can check it out then form your own opinion.
Not sure what you'll see as far as crisp passing since these guys haven't had a lot of time to play together, but you will see the speed and size of these young players. There will be plenty of hitting and maybe even a fight or two.
These 40 guys will be battling for a limited number of roster spots.
"It's going to be competitive with guys trying to make the team," Lumberjacks' coach Kevin Patrick said. "They all want to play in the premier junior hockey league in North America. And this is a great opportunity to see all our guys."
There's some rumble among Lumberjack brass that several players who will be here this week could get chosen in the NHL Entry Draft next week. Brendan Woods, Joel Vienneau and Casey Thrush all are rated in the latest NHL Central Scouting report.
That would be an instant feather in the cap of the expansion franchise to have a couple players' names read from the podium on draft day in Los Angeles.
There also will be college coaches and recruiters descending upon Walker Arena. Patrick said he's talked to 15 coaches who plan to attend and without a doubt, others will be dropping by unannounced.
This is a big change for local hockey fans. We were blessed with 50 years of pro hockey at Walker Arena and now we're shifting gears to the USHL.
And what better time than this week to get a June "hockey fix" and see what the future of Muskegon hockey is all about?
E-mail: email@example.com


text:
GAUTIER, Mississippi -- Gautier Police Chief Eddie Williams has told WLOX News his officers are investigating a shooting. One person was shot and has been taken to the hospital.
The shooting happened around 6 p.m. just off Ladnier Road in a neighborhood behind College Park Elementary School.
We'll bring you updates as they become available.


text:
Tom Smith, the Republican nominee for the U.S. Senate from Pennsylvania, released his economic-policy plan Wednesday, calling for a "flat tax" on all earners.
Smith, in a news conference at a City Avenue hotel, declined to specify what percentage of income he thought Americans should pay.
But he said a flat tax would be an improvement on the current tax code, which he described as full of "gimmicks" and "loopholes" and "10 times the length of the Bible without any of the good news."


text:
Even though Otis Smith and Stan Van Gundy have both been ousted from the Orlando Magic in favor of whiny superstar Dwight Howard, it seems the NBA's top center still wants out of Orlando, as reported by Chris Sheridan of SheridanHoops.
Unfortunately, the Dwight Howard drama is far from over. For the most part, NBA fans have grown tired of the endless tirade and attention-seeking drama that Dwight has orchestrated this year.
Somehow, some way, he always seems to be at the forefront of NBA news.
Despite all this, there are numerous NBA teams that remain interested in Mr. Howard. While he may be a massive whiner, he still is the NBA's premier center and a number of teams would give away the farm in order to acquire him.
While some teams could use him, there are a few that need to steer clear of anything involving Howard.