Neuraxial Labor Analgesia (Epidural / CSE / DPE)
🔹 1. Indications
- Maternal
request = sufficient indication (ACOG/ASA)
- ใช้เพื่อ:
- Pain
control
- เตรียม epidural catheter สำหรับ convert
→ C/S
anesthesia
🔹 2. Contraindications (สำคัญ)
Absolute (rare)
- Infection
at site
- Coagulopathy
- ↑ ICP (mass lesion)
Relative
- Thrombocytopenia
- Anticoagulant
use
- Severe
hypovolemia
🔹 3. Key Physiology
(High-yield)
- Stage
1 pain: T10–L1
- Stage
2 pain: S2–S4
👉 ต้อง block ครอบคลุมทั้ง 2 ระยะ
🔹 4. Technique Overview
✅ Epidural (standard)
- Continuous
analgesia
- Convert
to C/S ได้ง่าย
- Onset
ช้ากว่า
✅ CSE (Combined spinal-epidural)
- Rapid
onset (3–5 min)
- maintain
via epidural
- ↓ failure rate, ↓ drug dose
⚠️ Side effects:
- pruritus
- fetal
bradycardia ↑
✅ DPE (Dural puncture epidural)
- CSE แบบ ไม่ฉีด intrathecal drug
- ↑ block quality (better
sacral spread)
❗ Less used
- Single-shot
spinal → short
duration
- Continuous
spinal → PDPH (post
dural puncture headache) risk
🔹 5. Preparation ก่อนทำ
- IV
access
- Monitor:
BP + SpO₂ + FHR
- Equipment
+ lipid emulsion (LAST- local anesthetic systemic toxicity)
- Consent
- Aseptic
technique
📌 Lab:
- Routine
ไม่จำเป็นใน healthy
- check
platelet ถ้ามี risk
🔹 6. Drug Strategy
(High-yield clinical)
🎯 Principle
- Low
concentration + high volume
📌 Epidural (standard
regimen)
- Bupivacaine
0.0625–0.1% + fentanyl 2 mcg/mL
- Bolus:
10–20 mL
- Maintenance:
infusion / PCEA (patient-controlled epidural analgesia) / PIEB (programmed
intermittent bolus)
👉 ข้อดี:
- ↓ motor block
- ↑ maternal satisfaction
📌 Intrathecal (CSE)
- Fentanyl
10–15 mcg
- bupivacaine
1.25–3 mg
👉 Rapid onset +
synergistic effect
🔹 7. Maintenance
Techniques
- CEI
(continuous infusion)
- PCEA
(patient-controlled)
- PIEB
(programmed bolus) →
analgesia ดีขึ้น
🔹 8. Monitoring
During initiation
- BP q5
min × 15–20 min
- continuous
HR + SpO₂
- FHR ก่อน–หลัง
Maintenance
- BP
q30–60 min
- reassess
after top-up
🔹 9. Troubleshooting (สำคัญมาก)
🔸 Breakthrough pain → approach
1.
ประเมิน pain pattern
2.
check sensory level
3.
check catheter position
4.
top-up
🔸 Top-up strategy
- Mild
→ dilute LA bolus
- Moderate/severe
→ 0.125%
bupivacaine 6–10 mL
- Unilateral
→ lateral position +
bolus
- Sacral
pain → suspect full
dilation
❗ Red flag → replace catheter
- ต้อง top-up >1–2 ครั้ง
- block
ไม่สม่ำเสมอ
- analgesia
ไม่ดี
👉 สำคัญ: catheter
ที่ไม่ดี = risk fail conversion to C/S
🔹 10. Complications
Common
- Hypotension
- Pruritus
(opioid)
Serious
- LAST
(local anesthetic systemic toxicity)
- High
spinal
- Epidural
hematoma (rare)
👉 ต้องมี lipid
emulsion พร้อมใช้
🔹 11. Special Clinical
Use
🔸 Early epidural
(high-risk)
ควรใส่ early ใน:
- Preeclampsia
- TOLAC
(Trial of labor after cesarean delivery)
- Obesity
(BMI >40)
- Difficult
airway
- Twin
pregnancy
👉 ลด need
for GA ใน emergency
🔹 12. Instrumental
Delivery
Vacuum
- ใช้ epidural เดิมได้
Forceps
- ต้อง block แรงขึ้น
- bolus:
- Lidocaine
1–2%
- หรือ chloroprocaine
🔹 13. Key Takeaways (จำง่าย)
- Maternal
request = indication
- Low-dose
LA + opioid = standard
- CSE
= fastest onset
- Replace
catheter early if ineffective
- Always
monitor BP + FHR
- Prepare
for C/S conversion เสมอ