Epidural Anesthesia for
Postpartum Tubal
*AssistantProfessor
tResident
Address reprint requests to Dr. Vincent at
the Department of Anesthesia, University
of Iowa College of Medicine, Iowa City, IA
52242, USA.
Received for publication January 11, 1993;
revised manuscript accepted for publication
March 2, 1993. - - -
0 1993 Butterworth-Heinemann
J. Clin. Ant&h. 5:499491, 1993.
Using Epidural C
Pla&d during Labor
Robert D. Vincent, Jr., MD,* Robert W. Reid, MDT
Department of Anesthesia, University of Iowa College of Medicine, Iowa City, IA.
Study Objectives: To evaluate the success of epidural anesthesia for postpartum tubal
ligation using epidural catheters placed during labor and to determine whether patient
characteristics, timing of surgery, or technical factors (‘e.g., length of epidural catheter
inserted into the epidural space) influenced the success of subsequent epidural anesthesia.
Design: Retrospective stud..
Setting: University hospital labor and delivery suite.
Patients: 90 consecutive women scheduledfor postpartum tubal ligation usingepidural
catheters placed during labor.
Interventions: Epidural catheters were reinjected with 1.5% to 2% lidocaine with
epinephrine 5 pglml or 2% to 3% 2-chloroprocaine immediately before surgery.
Measurements and Main Results: 74% of the women received satisfato9 intrqer-
ative anesthesia using in situ epidural catheters. Reinjecting the catheter within 4 hours
of delivery was associated with a greater frequency of successful epidural anesthesia for
tubal ligation (95% vs. 67%; p = 0.029). There was no significant difference between
the two groups in the length of catheter inserted into the epidural space.
Conclusions: Although other factors may influence the timing of postpartum tubal
ligation after delivery, the success of epidural anesthesia for tubal ligation using in
situ epidural catheters is greater if surgery is performed shortly after delivery.
Keywords: Anesthesia, obstetric; anesthetic techniques, epidural; catheter,
epidural; postpartum tubal ligation.
Introduction
An advantage of epidural anesthesia for pain relief during labor in women
who desire sterilization after delivery is that the epidural catheter may be left in
place and reinjected later to provide anesthesia for postpartum tubal ligation.
Unfortunately, we have observed that epidural anesthesia often is unsuccessful
when these in situ catheters are reinjected just before surgery. The purpose
of this study was to evaluate the success of epidural anesthesia for postpartum
tubal ligation using epidural catheters placed during labor and to determine
whether patient characteristics, technical factors (e.g., length of epidural cathe-
ter inserted into the epidural space), or the interval between placement and
delivery or delivery and surgery influenced the success of subsequent epidural
anesthesia.
Materials and Methods
The protocol was approved by the University of Iowa Institutional Review
Board for research involving human subjects. Medical records were reviewed
J. Clin. Anesth., vol. 5, July/August 1993 289
Original Contributions

Table 1. Patient Demographic Data was not significantly different between groups (Table 2).
But the time between delivery and tubal ligation was
Successful Unsuccessful significantly less (P = 0.023) in the successful group than
(n = 64) (n = 23) in the unsuccessful group (Table 2). Also, the chance of
successful epidural anesthesia was greater (p = 0.029) if
Age (yr) 29 28 the catheter was reinjected within 4 hours of delivery
Parity 3 3
(Figure I). Finally, epidural anesthesia for tubal ligation
Weight (kg) 79 * 1 a3 z? 3
was successful on each of ten occasions when attempted
BMI (kg/m2) 29.0 f 0.5 30.2 2 1.2
Height (cm) 165 * 1 165 + 1 before regression of sensory blockade (median level =
Tt,, prior to reinjection).
Note: Mean and median values are given for age and parity, respec- The length of epidural catheter inserted into the epi-
tively. Measured data are expressed as means f SEM. There were dural space was not significantly different between the
no significant differences between the groups. successful and unsuccessful groups (4.1 + 0.1 cm and
BMI = body mass index. 3.9 f 0.2 cm, respectively). The length of epidural cathe-
ter at the skin was recorded at placement and again
before surgery in 11 women. In 2 women, the catheter
for 90 consecutive women scheduled for elective postpar- position was unchanged at the skin. In the remaining 9
tum tubal ligation between January 1989 and September patients, the catheter migrated outward to a more super-
1992 using epidural catheters placed during labor (in ficial position (median length of migration = 2 cm; range
situ catheters). Twenty-gauge, closed-tip, triple-orifice = 1 to 6 cm). Also, 3 epidural catheters were completely
epidural catheters (Burron, Bethlehem, PA) were placed dislodged from the skin between delivery and surgery.
during labor in all parturients. All catheters were secured
to the patient’s back with plastic tape. Immediately before Discussion
surgery, the epidural catheters were incrementally rein-
jetted with 1.5% to 2% lidocaine with epinephrine 5 kg/ Gastric emptying slows during labor.‘** Opioids given for
ml or 2% to 3% 2-chloroprocaine. analgesia during labor also delay gastric emptying.z+s This
Subsequent epidural anesthesia was defined as suc- is of concern in postpartum women for fear that gastro-
cessful [i.e., adequate patient analgesia was achieved with esophageal incompetence places them at greater risk for
epidural local anesthetic alone or in combination with regurgitation of gastric contents.4 Thus, some anesthesi-
intravenous (IV) opioids and/or benzodiazepines] or un- ologists prefer to delay at least 8 hours after delivery
successful (i.e., the epidural catheter became accidentally before anesthetizing women for postpartum tubal liga-
dislodged before surgery; the catheter was reinjected, tion to allow for more complete gastric emptying.5 Al-
but a potent inhalation drug was required to achieve though one would expect that this practice would reduce
adequate intraoperative anesthesia; or spinal anesthesia the risk factors associated with aspiration pneumonitis,
was given for surgery). In several patients, the length of James et al6 found no relationship between the time
epidural catheter visible at the skin recorded at place- interval after delivery and the volume and acidity of
ment and again just before surgery. Epidural catheter stomach contents when measured during tubal ligation.
migration was defined as the difference between these Therefore, our results support the administration of epi-
two measurements. dural anesthesia for postpartum tubal ligation soon after
Statistical analysis of continuous data was by unpaired delivery in the hope that the success of subsequent epi-
t-tests. The Mann-Whitney U test and the chi-square dural anesthesia will be optimized.
test with contingency correction were used to compare We hypothesized that epidural anesthesia for tubal li-
nonparametric data between groups. A value of p < 0.05 gation would be more reliable in women whose epidural
was considered statistically significant. catheters were inserted to a greater depth. We anticipated
that this would be especially true in larger women because
of the tendency to overestimate the length of the catheter
in the epidural space in obese patients.' Although our data
Results
did not support these hypotheses, we did observe that
Successful epidural anesthesia for postpartum tubal liga- many catheters migrated to a more superficial position in
tion was achieved in 64 of 87 women (74%) using epidural the epidural space after the initial placement. For this rea-
catheters placed during labor. We excluded 3 patients son, we always advance the catheter at least 4 cm into the
who had adequate sensory levels of anesthesia docu- epidural space in women who are considering tubal liga-
mented in the chart but were given nitrous oxide in tion after delivery. But we acknowledge that this practice
oxygen via face mask during surgery. (One of these may increase the frequency of unilateral blockade and epi-
women also received IV boluses of thiopental sodium). dural venous cannulation.8.9
There were no significant demographic differences Postpartum tubal ligation is a semiurgent surgical pro-
between the two groups (Table I). However, patients in cedure that should not take priority over the obstetric
the successful group tended to weigh slightly less than and anesthetic care of women in active labor. However,
patients in the unsuccessful group. if staffing requirements and obligations to other patients
The time from epidural catheter placement to delivery permit, one should consider reinjecting in situ epidural

290 1. Clin. Anesth.. vol. 5. lulv/Auaust 1993

 Reinjection of epidural catheters for postpartum tubal ligation: Vincent and Reid

Table 4. Success of Subsequent Epidural Anesthesia versus Time Intervals between Epidural Catheter Placement, Delivery, and
Postpartum Tubal Ligation

Successful Unsuccessful
(n = 64) (n = 23) p-value

Epidural catheter placement to delivery (hr) 3.6 t 0.4 2.8 * 0.4 NS

Second stage of labor (min) 42 + 6 40 + 9 NS
Epidural catheter placement to surgery (hr) 14.1 + 1.1 17.6 + 1.4 NS
Delivery to surgery (hr) 10.6 f 1.0 14.8 t 1.4 0.023

Note: Data are means f SEM.

NS = not significant.

100 ’

80 -

60 -

40 -

20 -

0”
c4 4-8 8-12 >I2
(n=20) (n=12) (n=40) (n-15)

Delivery to surgery interval (h)

Figure 1. Percentage of successful epidural anesthetics for postpartum tubal ligation (PPTL) verszLs time interval between
delivery and surgery. Successful epidural anesthesia was more likely if the catheter was reinjected within 4 hours of delivery
(p = 0.029).

catheters and proceeding with postpartum tubal ligation JW, Moshal MC: Gastric and lower oesophageal sphincter (LOS)
shortly after delivery to improve the probability of suc- pressures in early pregnancy. Br J Anuesth 1981;53:381-4.
cessful epidural anesthesia. 5. Rolbin SH: Anesthesia for postpartum sterilization surgery. In:
Shnider SM, Levinson G, eds. Anesthesiafor Obstetrics. Baltimore:
Williams & Wilkins, 1993:247-58.
6. James CF, Gibbs CP, Banner T: Postpartum perioperative risk
References
of aspiration pneumonia. Anesthesiology 1984;61:756-9.
Davison JS, Davison MC, Hay DM: Gastric emptying time in 7. Webster SG: Migration of epidural catheters [Letter]. Anaesthesiu
late pregnancy and labour. J Obstet Gynoecol Br Communw 1986;41:654.
1970;77:37-41. 8. Shnider SM, Levinson G, Ralston DH: Regional anesthesia for
O’Sullivan GM, Sutton AJ, Thompson SA, Carrie LE, Bull- labor and delivery. In: Shnider SM, Levinson G, eds. Anesthesia
ingham RE: Noninvasive measurement of gastric emptying in for Obstekes. Baltimore: Williams & Wilkins, 1993:135-53.
obstetric patients. Anesth Analg 1987;66:505-11. 9. Cousins MJ, Bromage PR: Epidurai neural blockade. In: Cousins
Holdsworth JD: Relationship between stomach contents and an- MJ, Bridenbaugh PO, eds. Neural Blockade in Clinical Anesthka
algesia in labour. Br J Anuesth 1978;50: 1145-B. and Management of Pain. Philadelphia: J.B. Lippincott,
Brock-Utne JG, Dow TG, Dimopoulos GE, Welman S, Downing 1988:253-360.

J. Clin. Anesth., vol. 5, July/August 1993 491