SK, Mcintire DO, Wiley J, et al: Labor analgesia and cesarean delivery. An individual patient meta-analysis of nulliparous women, Anesthesiology. 2004 Jan;l00(1):142-148.) sion (Chap. 52, p. 1014). Our practice pat (Lieberman, 1996; Rogers, 1999; Seyb, 1999). These observations prompted at least ive randomized trials, which showed that timing of epidural placement has no efect on the risk of cesarean birth, forceps delivery, or fetal malposition (Chestnut, 1994a,b; Ohel, 2006; Wong, 2005, 2009). Thus, withholding epidural placement until some arbitrary cervical dilation has been attained is unsupportable and serves only to deny women maximal labor pain relief.
he relative safety of epidural analgesia is relected by the extraordinary earlier experiences reported by Crawford (1985) from the Birmingham Maternity Hospital in England. Similarly, there were no anesthesia-related maternal deaths among nearly 20,000 women who received epidural analgesia in the MFMU Network study cited earlier (Bloom, 2005). And, Ruppen and associates (2006) reviewed data from 27 studies involving 1.4 million pregnant women who received epidural analgesia. hey calculated risks of 1: 145,000 for deep epidural infection, 1: 168,000 for epidural hematoma, and 1 :240,000 for persistent neurological injury.
Thrombocytopenia. For epidural analgesia, contraindications are similar to those with spinal analgesia (see Table 25-6). Although low platelet counts are intuitively worrisome, the level at which epidural bleeding might develop is unknown according to the American Society of Anesthesiologists Task tern includes the following: 1.
Women receiving unfractionated heparin therapy should be able to receive regional analgesia if they have a normal activated partial thromboplastin time (aPTT).
2.
Women receiving prophylactic doses of unfractionated heparin or low-dose aspirin are not at increased risk and can be ofered regional analgesia.
3.
For women receiving once-daily, low-dose low-molecularweight heparin, regional analgesia should not be placed until 12 hours after the last injection.
4.
Low-molecular-weight heparin should be withheld for at least 2 hours after epidural catheter removal.
5.
he safety of regional analgesia in women receiving twicedaily low-molecular-weight heparin has not been studied suiciently. It is not known whether delaying regional analgesia for 24 hours after the last injection is adequate.
Severe Preeclampsia-Eclampsia. Potential concerns with epidural analgesia in women with severe preeclampsia include hypotension as well as hypertension from pressor agents given to correct hypotension. Additionally, pulmonary edema following infusion of large volumes of crystalloid is a potential risk. These are outweighed by disadvantages of general anesthesia. Tracheal intubation may be diicult because of upper airway edema. Moreover, general anesthesia can lead to severe, sudden hypertension that can cause pulmonary or cerebral edema or intracranial hemorrhage.
With improved techniques for infusion of dilute local anesthetics into the epidural space, most obstetricians and obstetrical anesthesiologists have come to favor epidural block ade for labor and delivery in women with severe preeclamp sia. here seems to be no argument that epidural analgesia for women with severe preeclampsia-eclampsia can be safely used cians (Lucas, 2001).