![]() This phenomenon has been mentioned in the literature, but never fully described. She proceeded to an uneventful delivery with excellent analgesia from both the spinal and epidural portions of her analgesic. Analgesia remained excellent throughout this period. Another dose of 40 μg naloxone was given, with resolution of her symptoms, and they did not return. Approximately 30 min later, she again noted difficulty swallowing, and again the gag reflex was absent. 40 μg naloxone was given intravenously, and within a minute or two, the patient was able to swallow and her gag reflex had returned. Placing a cotton swab and tongue blade in the posterior pharynx revealed an absent gag reflex. Motor strength in the upper extremities was completely normal and was 3–4/5 in the lower extremities, as expected with the given dose of bupivacaine. Sensory block to ice was at about T8 or T7. It was rapidly determined that the difficulty was not with breathing but rather with swallowing. ![]() ![]() Approximately 10–12 min after spinal injection (with no epidural injection or infusion yet), the patient reported “difficulty breathing.” The oxygen saturation as measured by pulse oximetry throughout the procedure and at this time was 99–100% with the patient breathing room air. A 20-gauge epidural catheter was threaded into the epidural space. A 17-gauge Tuohy needle was used to identify the epidural space using loss of resistance to saline 4.5 cm deep to the skin the subarachnoid space was entered with a 27-gauge Whitacre needle, and 20 μg fentanyl and 2.5 mg bupivacaine were injected into the cerebrospinal fluid. ![]() The first case was a 23-yr-old, gravida 1 para 0 woman who received combined spinal–epidural analgesia for labor at cervical dilation of 4 cm. ![]()
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