A primigravida at term with mitral stenosis in labor wants analgesia for normal delivery. which form of Anesthesia to be used for her?

Epidural anesthesia during PregnancyCombined spinal-epidural analgesia during labor using intrathecal fentanyl 25 mcg produces good analgesia without major hemodynamic changes during the first stage of labor.During the second stage of labor, only the uterine contractile force should be allowed rather than the maternal expulsive effo that is always associated with the Valsalva maneuver. Therefore, the second stage of delivery should be cut sho by instrumentation.Supplementary analgesia for instrumentation with slow epidural boluses of fentanyl and a low concentration of bupivacaine reduces SVR and the cardiac pre-load.One of the major advantages of epidural analgesia is that it can be administered in incremental doses and that the total dose could be titrated to the desired sensory level.This coupled with the slower onset of anesthesia, allows the maternal cardiovascular system to compensate for the occurrence of sympathetic blockade, resulting in a lower risk of hypotension and decreased uteroplacental perfusion.Moreover, the segmental blockade spares the lower extremity "muscle pump," aiding in venous return, and also decreases the incidence of thromboembolic events.Invasive hemodynamic monitoring, judicious intravenous administration of crystalloid and administration of small bolus doses of phenylephrine maintain maternal hemodynamic stability.(Ref: William's Obstetrics, 22nd edition, pg no: 483)