OBSTETRIC ANESTHESIA

and ANALGESIA

JOSE ARNEL G. MANALILI, M.D.

Associate Professor in Anesthesia
Fatima College of Medicine
 LEARNING OBJECTIVES
At the end of the lecture, the student must be
able to:
 Discuss the maternal changes in pregnancy
 Explain the anesthesia implications of the maternal
changes in pregnancy
 Explain the general approach in anesthesia of an
obstetric patient
 Discuss the different techniques in providing anesthesia
for labor and delivery
 Discuss the different techniques in providing anesthesia
for surgery of an obstetric patient
 Give the anesthesia-of-choice in complicated
pregnancy
 MATERNAL
CHANGES IN
PREGNANCY
 CVS
 5% INCREASE IN TOTAL BLOOD VOLUME
 15 BEATS/MIN INCREASE IN HR
 40% INCREASE IN CO
 30% INCREASE IN SV
 500 ML/MIN INCREASE IN UTERINE BLOOD FLOW
 15% DECREASE IN SVR
AORTOCAVAL COMPRESSION
CLINICAL IMPLICATIONS OF CVS
CHANGES

 POSSIBLE DECOMPENSATION OF CARDIAC

PATIENTS
 SUPINE HYPOTENSIVE SYNDROME
 RESPIRATORY SYSTEM
 20 %INCREASED O2 CONSUMPTION
(100% DURING LABOR)
 50% INCREASED IN MINUTE VENTILATION
 DECREASED ARTERIAL pCO2
 DECREASED FRC
 EDEMA AND VENOUS ENGORGEMENT OF AIRWAY
MUCOSA
 CLINICAL IMPLICATIONS OF
RESPIRATORY CHANGES
 HIGHER RISK OF MATERNAL HYPOXIA
(PREOXYGENATION BEFORE GA IS LESS
EFFECTIVE)
 FASTER INTAKE OF INHALATIONAL AGENTS

 LOWER INHALATION AGENT REQUIREMENT

 DECREASE IN MAC 25-40%

 WORSENING OF MALLAMPATI SCORE
 HIGHER INCIDENCE OF DIFFICULT / FAILED

INTUBATION ( 10X)
 NEED FOR A SMALLER Endotracheal Tube
 AIRWAY TRAUMA DURING INTUBATION
PATIENT ASSESSMENT
Mallampati
 CENTRAL NERVOUS SYSTEM
 DISTENDED EPIDURAL VEINS
 LESS CSF VOLUME

 IMPLICATIONS
 MORE RAPID ONSET OF NEURAXIAL BLOCKADE
 LESS AMOUNT OF LOCAL ANESTHETIC
 GIT

 INCREASED GASTRIC VOLUME AND ACIDITY

 DELAYED GASTRIC EMPTYING
 DECREASED COMPETENCY OF LES DUE TO INC.
GASTRIN
 SHIFT IN THE POSITION OF THE STOMACH
 CLINICAL IMPLICATIONS OF GIT
CHANGES
 GASTRIC REFLUX /HEARTBURN
 ALL PARTURIENTS ARE CONSIDERED ON “FULL
STOMACH”
 INCREASED RISK OF ASPIRATION
 ASPIRATION PROPHYLAXIS FOR CS:
 clear antacid ( 15-30 ml of 0.3 M sodium citrate PO q 3 h (to
maintain gastric pH above 2.5)
 H2 blocker (ranitidine, 100-150 mg PO, 50 MG IV) or
metoclopramide (10 mg PO/IV)
LABOR AND DELIVERY
 LABOR

 First stage
– regular contraction to full cervical dilation

 Second stage
– full cervical dilation to delivery of
infant
 Third stage
– delivery of infant to delivery of
placenta
 PAIN OF CHILDBIRTH

Nociceptive pathways
involved

T10 – L1 during labor

plus
S2-S4 for delivery
 Is pain bad in labor?
Psychological stress can cause:
increased levels of catecholamines
hyperventilation

These may result in decreased uterine blood flow

leading to hypoxia and acidosis in the fetus
Factors affecting pain perception in
labor
 Mental preparation
 Family support
 Medical support
 Cultural expectations
 Underlying mental status
 Parity
 Size and presentation of the fetus
 Maternal pelvic anatomy
 Duration of labor
 Medications
ANALGESIA FOR LABOR AND
DELIVERY

 Non-pharmacological
 Parenteral
 Inhalational
 Regional
Analgesia- Non medication options

 Breathing exercises
 Autohypnosis
 Acupuncture
 White Noise/ Music
 Massage/ walking
 TENS
 Water bath
 Parenteral Medications
 Narcotics: meperidine, morphine, fentanyl,
nalbuphine

Advantages: relatively good analgesia

Disadvantages: nausea, vomiting, sedation,

neonatal depression (max. 10-20 min, 1-3 hours
after IV /IM meperidine dose), short duration of
action
 Parenteral Medications
 Sedatives/antianxiety:
 promethazine
 hydroxyzine

 benzodiazepine

 Ketamine
 Inhalation Medications
 Nitronox: 50:50 mixture of oxygen and
nitrous oxide
 Low dose Isoflurane in oxygen (0.7%)

 Enflurane 1%

Advantage:
awake patient with protective laryngeal
reflexes
Overdosage:
confusion, excitement, drowsiness
 REGIONAL TECHNIQUES
 Epidural, spinal, combined spinal-epidural

Advantages:
excellent pain control, minimal impact on
progress of labor with low doses, less drug
transfer to fetus, improved uterine blood
flow, decrease in birth trauma e.g. use of
forceps, minimal neonatal depression

Disadvantages: invasive technique, side

effects (hypotension, headache, itching,
nausea, urinary retention, limited mobility),
nerve damage, infection
 GENERAL CONSIDERATIONS
 Maternal considerations
 Risks to the fetus:
 Possible teratogenicity of anesthetic agents
 Intraoperative effects on uteroplacental blood
flow
 Increased risk of preterm labor/ risk of
abortion
 Maternal considerations
 Altered physiology
 Altered response to anesthesia and other
drugs
 Decrease in MAC
 Increased sensitivity to neuraxial agents
 Decreased plasma cholinesterase
 Decreased protein binding (more free drug)
 Fetal Considerations
 Teratogenicity:
 Limited information
 Guidelines based on
 a) effects on reproduction in animals;
 b) epidemiological surveys of OR personnel;
 c) studies of pregnancy outcomes in parturient
undergoing ante partum surgery
 Nitrous oxide has been shown to have a
teratogenic effect in rats during the first trimester
 No anesthetic agent is a proven teratogen in
humans
 Anesthetic agents deemed safe include:
thiopental,morphine, meperidine,fentanyl,
succinylcholine, NDMRs
 Anesthetic Considerations
 Anesthetic management in the parturient
should be directed to:
 Avoidance of hypoxemia
 Avoidance of hypotension
 Avoidance of acidosis
 Maintain PaCO2 in the normal range for the
parturient
 Minimize effects of aortocaval compression
 Prevent aspiration
 Preparation
 Preventing complications
 Choice of Anesthetic technique
 Effects on the fetus
 Preparation
 Premeds: antacid (sodium citrate)
 IV access and fluid bolus within 30 minutes of
operating (avoid glucose containing fluids)
 Left lateral tilt with wedge under right pelvis
 Routine Monitors: ECG, NIBP, pulse oximeter,
fetal monitoring
 Additional monitors for GAs: ETCO2, nerve
stimulator, temp probe
 Anesthetic techniques
 Local infiltration by surgeon
 Rarely performed
 Surgery must be done via midline incision, gentle
retraction, no exteriorization of the uterus
 Usually done to supplement a regional technique

 Regional anesthesia: spinal, epidural,

combined spinal-epidural

 General anesthesia
 Regional: Spinal Anesthesia
 Simple to perform
 Rapid onset
 Profound neural block
 Technique of choice for uncomplicated
elective caesarean sections and in many
emergency caesarean sections
 Regional: Epidural Anesthesia
 More technically challenging
 Slower onset
 Used when already placed for labor analgesia
 Useful in parturient where a slow, controlled
onset of block is needed
 Allows prolongation of block should surgery be
complicated
Regional: Spinal Anesthesia
Potential complications

 Hypotension
 Headache (rare ~1:100)

 Backache (temporary ~24hrs)

 Nausea/vomiting (secondary to BP,

narcotics)
 Urinary retention

 Neurological damage (very rare)

 Anaphylaxis (very rare)
Regional: Epidural Anesthesia
Potential complications

 Hypotension
 Headache (approx 1:100)

 Transient backache ~24hrs

 Urinary retention

 Unintentional spinal injection

 Intravascular injection of local anesthetic

 Neurological damage

 Infection
 Regional: Combined spinal-
epidural
 Used when the speed and density of a spinal
anesthetic, with the flexibility of prolonging the
block by supplemental increments of local
anesthesia via the epidural catheter, is required

 Complications: as mentioned for spinal and

epidural anesthesia
 General Anesthesia
Indications
 fetal distress during the 2nd stage
 tetanic uterine contractions
 breech extraction
 version and extraction
 manual removal of a retained placenta
 replacement of an inverted uterus
 psychiatric patients who became uncontrollable
 General Anesthesia
Effects on the Fetus
 Minimized by limiting time between uterine
incision and delivery to less than 3 minutes

 Infants exposed to GA have lower Apgar at one

minute but no difference at 5 mins

 No significant alteration in neurobehavioral

scores as compared to regional techniques
 SPECIAL CONSIDERATIONS
 PREGNANCY-INDUCED HYPERTENSION
 epidural anesthesia is the anesthesia-of-choice

 CARDIAC OBSTETRIC PATIENT

 mitral valve disease, aortic insufficiency, congenital
lesions with left-to-right shunting
 REGIONAL ANESTHESIA
 aortic stenosis, congenital lesions with right-to-left /
bidirectional shunting, primary pulmonary
hypertension
 GENERAL ANESTHESIA
KEY CONCEPTS
 ALL OBSTETRIC PATIENTS ARE CONSIDERED TO HAVE
A FULL STOMACH

 NEARLY ALL PARENTERAL OPIOID ANALGESICS AND

SEDATIVES READILY CROSS THE PLACENTA AND CAN
AFFECT THE FETUS
 PAIN RELIEF DURING LABOR REQUIRES NEURAL
BLOCKADE AT THE T10-L1 SENSORY LEVEL IN THE
THE 1ST STAGE OF LABOR, T10-S4 IN THE 2ND STAGE

 REGIONAL ANESTHESIA IS PREFERRED FOR

MANAGEMENT OF LABOR PAIN

 CONTINUOUS LUMBAR EPIDURAL ANESTHESIA IS THE

MOST VERSATILE AND THE MOST COMMONLY
EMPLOYED TECHNIQUE

 CONTINUOUS EPIDURAL ANESTHESIA ALLOWS A

BETTER “CONTROL” OVER THE SENSORY BLOCK
LEVEL THAN A SINGLE-SHOT TECHNIQUE
 EVEN WHEN ASPIRATION DOES NOT YIELD BLOOD OR
CSF, UNINTENTIONAL INTRAVASCULAR OR
INTRATHECAL PLACEMENT OF AN EPIDURAL NEEDLE
OR CATHETER IS POSSIBLE

 THE RISK OF SYSTEMIC DRUG TOXICITY IN EA IS

MINIMIZED BY SLOWLY ADMINISTERING DILUTE
SOLUTIONS FOR LABOR PAIN AND BY
FRACTIONATING THE TOTAL DOSE FOR CS INTO 5 ML
INCREMENTS
 LOCAL ANESTHETIC-OPIOID MIXTURE FOR LUMBAR
EPIDURAL ANESTHESIA DURING LABOR
SIGNIFICANTLY REDUCES DRUG REQUIREMENT

 DILUTE MIXTURE OF LOCAL ANESTHETIC AND OPIOID

IN EPIDURAL ANESTHESIA HAS LITTLE OR NO EFFECT
ON THE PROGRESS OF LABOR
 COMBINED SPINAL-EPIDURAL TECHNIQUE MAY
PARTICULARLY BENEFIT PATIENTS WITH SEVERE
PAIN

 SAB HAS A MORE RAPID, PREDICTABLE ONSET, MORE

DENSE BLOCK WITHOUT THE POTENTIAL FOR
SERIOUS SYSTEMIC DRUG TOXICITY
 HYPOTENSION IS A COMMON SIDE-EFFECT OF
REGIONAL ANESTHESIA AND MUST BE TREATED
AGGRESSIVELY WITH VASOPRESSORS,
SUPPLEMENTAL O2, LEFT UTERINE DISPLACEMENT,
AND IV FLUID BOLUSES TO PREVENT FETAL
COMPROMISE

 SPINAL OR EPIDURAL ANESTHESIA IS PREFERRED TO

GENERAL ANESTHESIA FOR CESARIAN SECTION
BECAUSE OF THEIR ASSOCIATION TO LOWER
MATERNAL MORTALITY