OBSTETRICS I – OB Analgesia – Anesthesia

Lecture by Irma A. Lee, F.P.O.G.S. ANALGESIA DURING LABOR

USTMED ’07 Sec C - AsM
1. Epidural Analgesia / Anesthesia
GOALS OF CHILDBIRTH PREPARATION
• Patient education concerning pregnancy, labor and
• Most effective
method of
delivery
intrapartum pain
• Relaxation training
relief
• Instruction in breathing techniques
• Uses local
• Husband (support person) participation anesthetics
• Early parental bonding (Bupivacaine,
Lidocaine,
NONPHARMACOLOGIC ANALGESIC TECHNIQUES Ropivacaine, 2
chloroprocaine,
A. Minimal Training Epinephrine)
• Emotional support
• Touch & massage • Other Indications for Epidural Analgesia
• Therapeutic use of heat & cold o Vaginal delivery of twins
• Hydrotherapy o Vaginal delivery of preterm infants
• Vertical position o Pre-eclampsia
B. Specialized Training o Patient with medical complications (mitral
• Biofeedback stenosis, spinal cord injuries, intracranial
• TENS neurovascular disease, asthma)
• Acupuncture
• Hypnosis • Contraindications of Epidural Analgesia
o Patient refusal or inability to cooperate
OBSTETRIC PAIN PATHWAYS o Increase intracranial pressure
o Infection at the site of needle puncture
A. Visceral pain o Coagulopathy
• From uterine o Uncorrected maternal hypovolemia
contractions and o Inadequate training or experience in the
cervical technique
dilatation
• Via visceral • Complications of Epidural Analgesia
afferent fibers o Hypotension
entering spinal o Inadequate analgesia
cord at T10-T12 o High or total spinal
and L1 o Urinary retention
o Headache
B. Somatic pain o Postdural puncture seizures
• from distention o Meningitis
of pelvic floor, o Back pain
vagina, perineum
• Via somatic • Bupivacaine
nerve fibers o Oftenly used local anesthetic for epidural
transmitted from analgesia
pudendal nerve o 8-10mL of 0.25% to 0.5% for 2 hrs
to S2-S4 o Peak effect achieved in 20 mins.
o Provide excellent sensory blockade with
minimal motor blockade

• Maintenance of Epidural Analgesia

a. Intermittent Bolus Injection
- Supplemental doses of local anesthetics
given for the duration of labor
- Results in blockade of sacral segments,
intense motor blockade or both

b. Continuous Infusion
- More popular for maintaining epidural
analgesia
- Benefits:
 Easy to maintain level of analgesia
 More stable maternal VS
 Decrease risk of systemic anesthetic
toxicity

2. Spinal Analgesia / Anesthesia

• Low spinal block or saddle block
• For vaginal delivery requiring perineal anesthesia
• Other indications: delivery of preterm fetuses, low
forceps delivery, cerclage, completion curettage
• All local anesthetics can be used
o Lidocaine – short duration
o Tetracaine intermediate to
o Bupivacaine long duration

3. Alternative Regional Anesthetic Techniques

a. Paracervical Block
o Used during first stage of labor
o No sensory or motor blockade
 o Blocks transmission of impulse through the
paracervical ganglion(Frankenhausen’s
ganglion)
o Fetal complications: bradycardia
o Maternal complications (hematoma, systemic
local anesthetic toxicity, vasovagal syncope)
o Agent of choice: 2-chloroprocaine
b. Pudendal Nerve Block
o Pudendal nerve provides sensory innervation
for the lower vagina, vulva and perineum;
motor innervation to perineal muscles and
external anal sphincter
o Analgesia for spontaneous vaginal delivery and
outlet forceps delivery
o Complications (systemic local anesthetic
toxicity, hematoma)
c. Perineal Infiltration
o Most common local anesthetic technique for
vaginal delivery
o Anesthetic for episiotomy and repair
4. Systemic Analgesia
• Used when conditions contraindicated the use of
regional (hemorrhage, coagulopathies)
• Epidural anesthesia is not available
• Risks for epidural anesthesia
a. Opioids
o Lipid soluble with low molecular weight easily
crosses the placenta
o Causes neonatal respiratory depression
o Result in decrease beat-to-beat variability of
FHR
(1) Meperidine (Demerol)
o Most widely used opioid for labor analgesia
o Given at 25-50 mg IV or 50-100 mg IM every 2-
4 hrs.
o Onset of analgesia 5 minutes after IV and 45
minutes after IM
o Often used with Phenothiazines to decrease
nausea and vomiting
o To prevent neonateal respiratory depression,
delivery should be within the 1st hr. or more
than 4 hrs. after IV administration
o Decrease FHR variability 25 minutes after IV or
40 minutes after IM administration but
recovers within 60 minutes
(2) Nalbuphine (Nubain)
o Demonstrate ceiling effect for respiratory
depression at 30 mg dose
o 10-20 mg every 4-6 hrs.
o Onset within 2-3 minutes after IV and within
15 minutes after IM
o Less maternal nausea and vomiting
o More maternal sedation and dizziness
(3) Naloxone ( Narcan)
o Opioid antagonist to reverse neonatal
respiratory depression
o Given at 0.1mg/kg of a 1mg/mL IV or IM
 o Total spinal blockade due to excessive dose of
analgesic
o Spinal headache due to CSF leakage
o Convulsions
o Bladder dysfunction

• CONTRAINDICATIONS
o Hypotension
o Coagulopathies
o Neurologic disorders
o Infection on sites of skin puncture

• MANAGEMENT OF SPINAL BLOCK COMPLICATIONS

b. Inhalational Analgesics
o Nitrous Oxide
 Gas anesthetic
 Given intermittently as 50% nitrous
oxide in 50% oxygen(NITRONOX) by
mask or mouthpiece
 For forceps delivery
 Part of balanced general anesthesia
o Halogenated Agents
 Volatile anesthetics
 Causes dose related uterine smooth
muscle relaxation (halothane,
enflurane, isoflurane)
 For internal podalic version of the
2nd twin, breech decomposition and
replacement of acute uterine
inversion
 With cardiodepressant and
hypotensive effects
 Hepatotoxic
• Problems Regarding Use of Inhalational Anesthetics
o Need for specialized vaporizers
o Concern regarding pollution of labor and
delivery room
o Incomplete analgesia
o Potential for maternal amnesia
o Potential for loss of protective airway reflexes
and pulmonary aspiration of gastric contents
c. Intravenous Drugs During Anesthesia
o THIOPENTAL(PENTOTHAL)
 Short-acting barbiturate
 Used with a muscle relaxant
(succinylcholine) prior to tracheal
intubation
 Induces sleep, poor analgesic
 Causes neonatal respiratory
depression
 Used during second stage of labor,
short minor gynecologic procedures
o Hypotension
 Uterine displacement
 Hydration with 0.5 to 1 L of NSS
 Ephedrine 5-10 mg/IV
o Total spinal block
 Treat associated hypotension
 Tracheal intubation
 Ventilatory support
2. Continuous lumbar epidural block
• block is from T8-S5 dermatomes
• Opiates are added to avoid motor block
3. COMBINED SPINAL - EPIDURAL TECHNIQUES
• Provide effective analgesia for labor and cesarean
delivery
4. BALANCED GENERAL ANESTHESIA
• Uses nitrous oxide, thiopental and succinylcholine
• Causes maternal and fetal CNS depression
• Major hazard is aspiration pneumonitis
• PROPHYLAXIS FOR ASPIRATION DURING GENERAL
ANESTHESIA
o Fasting for 8 hrs
o Histamine H2 antagonists to reduce gastric
activity (Cimetedine)
o Sellick maneuver – skillful tracheal intubation
with pressure on cricoid cartilage to occlude
esophagus
• NGT
• Awake extubation
5. LOCAL ANESTHETIC BLOCK
• emergency CS in the absence of anesthesiologist
• to augment patchy regional block given in an emergency

o KETAMINE (KETALAR)
 Sedative, good analgesia prior to
delivery
 Avoid in hypertensive patients
 Induces delirium and hallucinations

o PROPOFOL(DIPRIVAN)
 Sedation for short surgical
procedures
-fin-
ANESTHESIA FOR CESAREAN SECTION
audrey_cl@yahoo.com
1. Spinal block
• For elective cesarean sections
• Level of sensory block up to T8 dermatome
• Larger dose of anesthetic agent
o Tetracaine 8-10 mg
o Bupivacaine 12 mg
o Lidocaine 50-75 mg

• COMPLICATIONS
o Hypotension due to vasodilatation from
sympathetic blockade and veno-caval
compression