Evidence Based Nursing

General Question

Labor pains: Is Spinal Anesthesia a better alternative to Epidural Anesthesia with regards to
Relieving pain caused by contractions, Time Efficiency, Costs, need for additional analgesia, and
Complications for Cesarean Section Delivery?

 PICO

Patient Intervention Comparison Outcome

Focus population
Mothers who are a
candidate for Cesarean
Section Delivery, the ones
with complications during
pregnancy or labor
Use of Spinal Use of Epidural The patient will by attain a
Anesthesia Anesthesia healthy state by means of
having a successful and
comfortable delivery
through reducing or
eliminating pain throughout
the birthing process.

The Final Diagnosis of the patient is “Gravida 2 Para 2 (2002) Pregnancy Uterine Term,
cephalic, delivered to alive Baby Boy, APGAR Score 9,9, birth weight 3,750 grams, LGA, S/P
LSTCS I Secondary to Secondary Arrest in Cervical Dilatation Secondary to CPD Midpelvis”.
The mother underwent into low segment transverse Cesarean Section Delivery under Spinal
Anesthesia because as of the internal examination during the 8 th hour of labor, the mother is still
6 cm dilated and still at active phase of labor when it is time when there should be a full
dilatation of 10 cm. There is a Cephalopelvic disproportion Midpelvis and the baby was also
Large for Gestational Age with a birthweight of 3,750 grams when the normal birthweight
should only be between 2,500 to 3,400 grams. The Chief complaint of the mother is Labor pains.
Few minutes prior to admission, she complained of uterine contractions occurring every 5
minutes with increasing frequency, lasting for 20-30 seconds with associated hypogastric pain
and vaginal spotting. Upon the 2nd hour, contractions were still moderate, lasting for 30-40
seconds occurring every 3-5 minutes’ interval. Contractions were strong, lasting for 40-50
seconds occurring every 2-3 minutes’ interval, Intravenous oxytocin was started during the 4 th
hour. The contractions during the 6th hour and 8th hour were the same with strong contractions,
lasting for 50-60 seconds occurring every 2-3 minutes’ interval. Therefore, the top final priority
among the nursing diagnosis is Acute Pain Related to Uterine Contractions as Evidenced by
Verbalization of Labor Pains.
Uterine muscle contractions and pressure on the cervix cause pain during labor. The pressure of
the baby on the bladder and bowels, as well as the stretching of the birth canal and vagina as the
baby passes through the birth canal, can cause pain. Women don't often seek pain relief because
of the severity of their labor pain. It's usually the intense nature of the pain and the amount of
time it lasts with each contraction. For most cesarean deliveries, a spinal block or epidural is
preferred.
For women who are not in labor but require a Cesarean delivery, spinals are normally the first
option of anesthetic. In spinal anesthesia, also known as a spinal block, the medication is injected
into the cerebrospinal fluid in the "subarachnoid space," which is closer to the spinal cord. The
entire lower half of the body becomes numb as a result of this. Spinal blocks are more effective
than epidurals and need less anesthetic medication. In an epidural, in the thoracic or lumbar
regions of the spine, the anesthetic is inserted into the "epidural space" surrounding the spinal
cord. Only the nerves leading to the area of the spinal cord where the anesthetic was injected are
numbed. After 10 to 20 minutes, epidurals begin to relieve pain. It's worth noting that severe
Post-dural puncture headache (PPDH) occurs only in patients who have undergone epidural
anesthesia. Although in the hands of experienced professionals, a PDPH rate of about 0.5 percent
is possible. The cost of spinal block is lower.

The charts of 47 patients who had undergone epidural and spinal anesthesia for cesarean section
were analyzed in order to assess time management, costs, charges, and complication rates. The
average operating room time for patients who received epidural anesthesia was slightly longer
than for those who received spinal anesthesia. Despite the fact that spinal anesthesia produces a
denser motor block than epidural anesthesia, time spent in the post-anesthesia treatment unit did
not increase (PACU). Using lidocaine as a spinal anesthetic may have resulted in shorter PACU
unit times. Spinal anesthesia was easier to administer and patients were more relaxed during the
procedure. This result is not surprising, given that an epidural block takes longer than a spinal
block. To administer an epidural block, the anesthesiologist must move slowly with the epidural
needle to prevent a Dural puncture, thread and tape the epidural catheter, give a test dose and
monitor the patient for 3-5 minutes to rule out IV or intrathecal placement, and administer the
entire local anesthetic dose incrementally. Furthermore, epidural anesthesia takes longer to start
than spinal anesthesia. The time variations caused by these factors are sufficient to account for
the 17-minute difference in OR time observed. Furthermore, some have stated variations between
the strategies of 22 minutes and 18 minutes. In the epidural group, additional intraoperative
intravenous analgesics and anxiolytics were needed more frequently than in the spinal group. In
the epidural group, 38 percent of patients received intraoperative IV analgesic or anxiolytic
drugs, compared to only 17 percent in the spinal group. With spinal anesthesia, there was less
need for supplementary intraoperative analgesia, indicating that these patients were more relaxed
than those who had epidural anesthetics. This could be due to spinal anesthesia's superiority. In
addition, more patients in the spinal group received fentanyl in conjunction with morphine, a
practice which improves the quality of spinal anesthesia. Six patients in the epidural group and
none in the spinal group experienced major complications that were reported in the anesthetic
record or postoperative notes. One Dural puncture, one intrathecal catheter, one intravascular
needle and catheter, and three ineffective blocks were among the complications in the epidural
group. One of the ineffective blocks was converted to a spinal anesthetic, another epidural
catheter was implanted, and the catheter was modified. Spinal anesthesia has a lower risk of
procedural complications, possibly because it is theoretically easier to administer. Based on costs
for the extra 17 minutes spent in the OR, cost estimates found that patients were paid an average
of $260 more for OR use and anesthesia specialist fees with epidural than with spinal anesthesia.
Patients stayed in the PACU longer after spinal block than after epidural block, despite the
benefits perceived by anesthesiologists. One essential aspect not discussed in this analysis is the
higher frequency of hypotension associated with spinal anesthesia. However, since hypotension
is normally effectively handled with volume loading, vasopressors, and left uterine displacement,
this is not included as a complication. It has no harmful effects on the fetus as it is temporary.

In another study, 163 parturient were given spinal anesthesia and 96 were given epidural
anesthesia, and the two groups were compared. While high-level blocks have been identified in
the Spinal Anesthesia group, no patient in the study had a high-level block impairing breathing
or requiring intubation. The time from anesthesia to surgical incision and overall anesthesia time
were also shorter in the Spinal group than in the Epidural group. Spinal also has a faster onset
and higher operating room utilization rate than Epidural. As a result, in the hospital, Spinal is
often used for Cesarean Section because obstetricians agree that the baby should be delivered as
soon as possible. Thus, in the Spinal group, less use of additional intraoperative analgesics and
sedatives may mean better anesthetic efficiency and a lower intraoperative pain score. The two
groups had comparable maternal satisfaction and neonatal outcomes, but patients in the Spinal
group had lower postoperative pain scores when Neuraxial morphine was added. Some
anesthesiologists also prefer spinal anesthesia to Epidural because of its fast onset and sufficient
motor blockade, as well as Epidural's high failure rate. The epidural group had 50 cases of
unintended Dural puncture, 50 cases of catheter manipulation, 25 cases of catheter replacement,
and 15 cases of epidural painless labor failure. In conclusion, spinal anesthesia may be preferable
to epidural anesthesia for cesarean section. It's easier to do, patients are more relaxed,
complication rates are lower, and it's less expensive.

References:
Huang, C. et al. (2015). A comparison of spinal and epidural anesthesia for cesarean section
following epidural labor analgesia: A retrospective cohort study. 53 (1), 7-11.
https://doi.org/10.1016/j.aat.2015.01.003
Riley, E. et al. Spinal Versus Epidural Anesthesia for Cesarean Section: A Comparison of Time
Efficiency, Costs, Charges, and Complications. Anesthesia & Analgesia. 80 (4), 709-712.
https://journals.lww.com/anesthesia-analgesia/pages/results.aspx?txtKeywords=DOi
Cleveland Clinic. (2018). Pregnancy: Epidurals & Pain Relief Options During Delivery.
Retrieved from https://my.clevelandclinic.org/health/articles/4450-pregnancy-epidurals--pain-
relief-options-during-delivery