The aim of this study is to evaluate the impact of lumbar spine ultrasound on the success rate and efficiency of labor epidural placement in the lateral position. The investigators hypothesize that ultrasound imaging of the lumbar spine of women in early labor will yield similar ultrasound results when done immediately prior to epidural placement. The investigators also hypothesize that the use of ultrasound with landmarks marked and depth to the epidural space estimated will facilitate epidural placement in terms of both efficiency (time required for placement) and efficacy of pain relief.
Several studies have demonstrated a significant benefit in pre-procedural ultrasound for epidural placement by anesthesia residents, particularly when performed in the obese population. To the investigators knowledge, however, no studies have evaluated this teaching modality for the lumber epidural technique in the lateral position. Formalizing the educational process for this less frequently performed, highly technical and critical skill may have a profound impact on trainee learning curves, and may enhance the overall success and efficiency of epidural placement, quality of analgesia provided, and safety of the procedure.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
OTHER
Masking
SINGLE
Enrollment
28
A baseline lumbar ultrasound in a standardized lateral position (by bed markings) will be performed with the midline and L3-L4 interspace marked, and estimated depth to the epidural space recorded. A second lateral lumbar ultrasound will be performed immediately prior to placement at the time of epidural request. The bed position will be standardized with lines drawn down the back, at the flexion of the knee, and heel of the foot. The sonographic measurements will include the midline, the L3-4 interspace, (both marked at the skin surface), and the measured depth to the ligamentum flavum (in centimeters).
Brigham and Women's Hospital
Boston, Massachusetts, United States
Depth to the epidural space (cm) from baseline ultrasound compared to pre-placement ultrasound.
Measured depth to the epidural space (cm) from baseline ultrasound compared to pre-placement ultrasound, measured with a 2-5 MHz curvilinear ultrasound probe at the lumbar spine, midline, at level L3-4.
Time frame: From enrollment to time of epidural placement, approximately 5 hours
Time required for epidural placement
Time required for placement (T0 = insertion of needle for subcutaneous lidocaine infusion prior to epidural needle placement). Tfinal = time at complete removal of Weiss epidural needle after catheter is threaded into the epidural space.
Time frame: From enrollment to time of epidural placement, approximately 5 hours
Need for assistance from additional anesthesiologist
Need for assistance from additional anesthesiologist
Time frame: From enrollment to time of epidural placement, approximately 5 hours
Number of attempts at epidural placement
defined as number of times the Weiss epidural needle enters the skin
Time frame: From enrollment to time of epidural placement, approximately 5 hours
Incidence of paresthesias
Paresthesia defined as pain with needle or catheter insertion
Time frame: From enrollment to time of epidural placement, approximately 5 hours
Labor pain at time of 30 minutes after placement is complete.
Labor pain rated on a visual analog scale (VAS)
Time frame: From enrollment to time of epidural placement, approximately 5 hours, plus 30 minutes.
Rate of epidural replacement for inadequate analgesia
Inadequate analgesia determined as VAS \>3 despite catheter adjustment and/or epidural dose adjustment.
Time frame: From enrollment to time of epidural placement, approximately 5 hours
Rate of inadvertent dural puncture at the time of placement.
Defined as cerebrospinal fluid aspiration through needle or catheter.
Time frame: From enrollment to time of epidural placement, approximately 5 hours
Midline measurement from baseline ultrasound compared to pre-placement ultrasound.
Measured midline (anatomical marking) from baseline ultrasound compared to pre-placement ultrasound, measured with a 2-5 MHz curvilinear ultrasound probe at the lumbar spine, midline.
Time frame: From enrollment to time of epidural placement, approximately 5 hours
L3-L4 lumbar spine level measured from baseline ultrasound compared to pre-placement ultrasound.
Measured L3-L4 lumbar spine level from baseline ultrasound compared to pre-placement ultrasound, measured with a 2-5 MHz curvilinear ultrasound probe at the lumbar spine, paramedic.
Time frame: From enrollment to time of epidural placement, approximately 5 hours
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