PAIN MANAGEMENT FOR

OBSTETRIC WITH
NEUROAXIAL ANALGESIA
Dr Mahmud MSc, SpAn, KMN, FIPM
Division of Pain of Department of Anesthesiology and Intensive Care
Therapy Sardjito Hospital-Medical Faculty Gadjah Mada University
Yogyakarta
 Pain Management for Obstetric with
Neuroaxial Block
• Physiologic Changes of Pregnancy
• Neuraxial Analgesia and the Progress of Labor
• Labor Pain Pathways
• Physiology of Labor Pain
• Drug Response in Pregnancy
• Anesthesia for Labor
• Anesthesia for Cesarean Section
• Adjuvant and Alternative OB Blocks
• Complications
INTRODUCTION

Ray L. Paschall 2012

Physiologic Changes of Pregnancy
• Total body water change (6.5–8.5 L gain at term) is impressive and is a
significant hypervolemic adaptation of pregnancy.
• Multiple consensus summaries of important physiologic and anatomic
changes are available for review

Ray L. Paschall 2012

Physiologic Changes of Pregnancy 1.
Cardiovascular Changes During Pregnancy
• Systolic and diastolic blood pressure decrease until midpregnancy
with a return to prepregnancy values by term.
• Decreased systemic vascular resistance 20% .
• Increased intravascular volume by 25–40%.
• Increased heart rate by 15–20% and cardiac output by 30–50%.
• ncreased total blood volume by 25% and plasma volume by 40–45%
which is reflected in increased SV.
• Aortocaval compression with supine position. CO decreases 14%.
• Autotransfusion with uterine contraction can also add a 300–500-mL.
Ray L. Paschall 2012
Physiologic Changes of Pregnancy
2. Pulmonary Changes During Pregnancy
• Elevated diaphragm.
• Increased upper airway edema and friability.
• Decreased functional residual capacity 20%.
• Increased minute ventilation 40–50%.
• Partially compensated respiratory alkalosis, pCO2 27–32 mmHg, pH 7.40–7.45.
• Depleted bicarbonate, 17–22 mEq implying limited buffering capacity.
• Oxygen consumption is increased 20% which creates a tendency for rapid
maternal and fetal hypoxia and maternal rapid desaturation during supine posi-
tion and during intubation.

Ray L. Paschall 2012

Physiologic Changes of Pregnancy
3. Hematologic/Laboratory Changes During Pregnancy
• Physiologic anemia.
• Leukocytosis.
• Slight decrease in platelet count.
• Fibrinogen doubled at term.
• Pregnancy is a hypercoagulable state with increases in most
procoagulant factors and a decrease in some of the natural inhibitors.
• BUN and creatinine decrease as a result of increased glomerular
filtration rate.

Ray L. Paschall 2012

Physiologic Changes of Pregnancy
4. Gastrointestinal/Endocrine Changes During Pregnancy
• Decreased gastric motility and emptying representing an increased
risk of aspiration due to progesterone effects. Gastrin secretion
increases and motilin secretion decreases.
• Bowel displaced cephalad in third trimester.
• Normal pregnant woman will remain euthyroid.
• Pregnancy conveys resistance to insulin due to human placental
lactogen.
• Neuraxial analgesia effectively mitigates many of the physiologic
changes that can be detrimental to labor. If pain or stress causes
maternal hyperventilation,
Ray L. Paschall 2012
Neuraxial Analgesia and the Progress of Labor
• Neuraxial labor analgesia remains a controversial subject regarding
the potential to slow the progress of labor and resultant delivery.
• Neuraxial labor analgesia  may prolong labor and increase the rate
of operative delivery.
• Some observational studies have loosely associated neuraxial
analgesia with prolonged labor and higher rates of instrument and
cesarean delivery.
• There is no clear causal link to any of these findings. Controlling for
the variable of early painful labor suggests that independent of
neuraxial analgesia, parturients with early pain have a higher
incidence of dystocia that would require instrumental deliveries
Ray L. Paschall 2012
• Higher cesarean  influenced by nonmedical factors such as provider density,
private insurance, the capacity of the local health care system, and malpractice
pressure. Areas with higher usage rates perform the intervention in medically less
appropriate populations – that is, relatively healthier births and do not see
improvements in maternal or neonatal mortality.
• A meta-analysis concluded that neuraxial analgesia does not increase the risk of
cesarean delivery.
• Wong et al. the provision of early analgesia via CSE will decrease total labor time
compared to narcotic analgesia. The beta-2 effect of epinephrine is to act as a
known myometrial relaxant that could prolong labor and negatively impact the
fetus due to increased oxygen consumption if maternal stress or pain responsible
for raising epinephrine levels is not attenuated.
Ray L. Paschall 2012
Labor Pain Pathways
• Labor pain is transmitted from low thoracic, high lumbar, and low
sacral nerve roots which are segmentally involved as labor stages
change

Ray L. Paschall 2012

 Physiology of Labor Pain

Pain

Medulation
Descending
modulation Dorsal Horn

Ascending
Physiology of Labor Pain
Dorsal root ganglion
Conduction
input

Transduction
Spinothalamic Peripheral
tract nerve

Trauma
Peripheral
nociceptors

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.
Modified by AHT
Drug Response in Pregnancy

Holger K. Eltzschig 2003

Anesthesia for Labor
• Epidurals or combined spinal-epidurals (CSE) offer the best solution
for a labor expected to end with vaginal delivery.
• A rule of thumb is that 1–2 mL of epidural local anesthetic per
segment to be blocked will be needed to establish the desired level of
conduction analgesia.
• Morbid obesity has been shown to cause a dramatic minimum local
anesthetic concentration change requiring approximately 40% less
infusate to achieve desired anesthesia. Obesity usually results in a 2-
dermatomal higher spread from an equal injection volume in a
nonobese patient
Ray L. Paschall 2012
• CSE can be argued to be the single best choice for labor analgesia
since Wong has shown that shorter labor, better analgesia, and no
change in operative delivery exist even with early neuraxial analgesia

Ray L. Paschall 2012

Adjuvant and Alternative OB Blocks
• Paracervical block
• Pudendal block
• Paravertebral blocks
• TAP block

Ray L. Paschall 2012

Complications
• High Block
• Pulmonary Aspiration
• Hypotension
• Local Anesthetic Toxicity
• Spinal Headache
• Neurologic Complication
• Postpartum Back Pain
• High Risk Anesthetic Patients
• Hypertensive Disorders of Pregnancy
• Maternal Hemorrhage
• Placenta Previa
Ray L. Paschall 2012
Postpartum Back Pain
• Epidural analgesia has been clearly shown not to be a contributing risk. Suggested
causes for long-term backache postpartum include change in pelvic tilt,
ligamentous relaxation causing spinal anatomy changes due to the release of the
hormone relaxin at delivery, musculoskeletal injury or stretch not appreciable due
to analgesia or excitement of delivery and more. It is now clear that the use of
epidural analgesia is not a direct cause of postpartum backache nor does it
modify the risk of developing backache.
• Can an obstetric epidural cause adhesive arachnoiditis has been asked and
functionally answered in the negative. Adhesive arachnoiditis is particularly
painful and debilitating and an extremely rare potential complication of
obstetrical epidurals and the infusions commonly run in them

Ray L. Paschall 2012

Standard orders and nursing procedure
protocols
• To maximize the effectiveness of epidural analgesia,
• Minimize the risk of complications,
• Improve recognition
• Treatment of adverse effects,
• Standard orders, and nursing procedure protocols are recommended.
 The aim is to try and improve the quality of clinical decision
making rather than to dictate clinical practice.

Pamela E. Macintyre 2015

Standard orders
• Orders for the local anesthetic and/or opioid infusion and/or bolus
doses that can be given.
• Nondrug treatment orders and any monitoring and documentation
requirements, which allows a regular assessment of the progress of
each patient and for rational changes to be made to epidural infusion
orders so that treatment is individualized
• Instructions for the management of inadequate analgesia as well as
adverse effects

Pamela E. Macintyre 2015

Pamela E. Macintyre 2015
Monitoring and documentation requirements
• Pain score, functional activity score, sedation score, and respiratory
rate.
• Blood pressure and heart rate.
• Sensory block.
• Motor block

Pamela E. Macintyre 2015

Nursing procedure protocols
• The institution’s policy on accreditation (credentialing) of nursing staff
• Mechanisms for checking and discarding of opioids
• Monitoring and documentation requirements
• Instructions for:
• Administration of bolus doses
• Checking the amount of drug delivered (from the infusion pump display)
• against the amount remaining in the syringe/infusion bag
• Checking the infusion pump settings against the prescription (e.g., at the change of each
shift)
• Checking the epidural insertion site and dressing
• Checking and documenting that the catheter is complete after removal
• The setting up and programming of infusion pumps
• The management of equipment faults and alarms
• Mobilization of the patient Pamela E. Macintyre 2015
 References
• Ray L. Paschall. Obstetric Anesthesiology. In Essentials of Regional Anesthesia.
Chapter 28. Spinger science. 2012. P 689-722.
• Ipsita Chattopadhyay, Srabani Basu, Amarendra. Timing of Administration of
Epidural Analgesia and Risk of Operative Delivery in Nulliparous Women: A Case–
control Randomised Study. Journal of Obstetric Anaesthesia and Critical Care.
Volume 8. 2018. P 16-19.
• Pamela E. Macintyre, Stephan A. Schug. Epidural and intrathecal analgesia. In
Acute Pain Management Practical Guide. 4 ed. Chapter 9. 2015. P 148- 150.
• Holger K. Eltzschig, Ellice S. Lieberman, and William R. Camann. Regional
Anesthesia and Analgesia for Labor and Delivery. N engl j med 348;4. 2003. P 319-
332.