ANESTHESIA

 AND  ANALGESIA   Principles  of  Pain  Relief  

  • Labor  pain  is  a  highly  individual  reflection  of  variable  stimuli.  
MATERNAL  RISK  FACTORS  THAT  SHOULD  PROMPT  ANESTHESIA  CONSULTATION:   • These   stimuli   are   modified   by   emotional,   motivational,   cognitive,   social,   and  
1. Marked  Obesity   cultural  circumstances  
• Choice   among   a   variety   of   methods   and   individualization   of   pain   relief   is  
2. Severe  edema  or  anatomical  abnormalities  
desirable  
Face,  neck,  spine  including  trauma  or  surgery  
 
3. Abnormal  dentition,  small  mandible,  difficulty  opening  m outh   Nonpharmacological  Methods  of  Pain  Control  
4. Extremely  short  stature,  short  neck,  or  arthritis  of  the  neck   1.LAMAZE  
5. Goiter   • Pain   often   can   be   lessened   by   teaching   pregnant   women   relaxed   breathing  
6. Serious  maternal  medical  problems   and  their  labor  partners  psychological  support  techniques  
• The   presence   of   a   supportive   spouse   or   other   family   member,   of  
Cardiac,  pulmonary,  neurological  disease  
conscientious  labor  attendants,  and  of  a  considerate  obstetrician  who  instills  
7. Bleeding  disorders   confidence,  have  all  been  found  to  be  of  considerable  benefit.  
8. Severe  preeclampsia   2.  CLINICAL  HYPNOSIS    
9. Previous  history  of  anesthetic  complications   • Power   of   the   mind   to   heal   the   body;   increases   of   beta   endorphins   in   the  
10. Obstetrical  complications  likely  lead  to  operative  delivery     peripheral  blood  
Placenta  previa  or  higher-­‐order  multiple  gestation   3.  ACUPUNCTURE  
 
 
 
Goals  for  Optimizing  Obstetrical  Anesthesia  Services    
PARENTERAL  AGENTS  
! Availability   of   a   licensed   practitioner   who   is   credentialed   to   administer   an  
appropriate   anesthetic   whenever   necessary   and   to   maintain   support   of   vital  
functions  in  an  obstetrical  emergency  
! Availability  of  anesthesia  personnel  to  permit  the  start  of  a  cesarean  delivery  
within  30  minutes  of  the  decision  to  perform  the  procedure      
! Anesthesia   personnel   immediately   available   to   perform   an   emergency  
cesarean  delivery  during  the  active  labor  of  a  woman  attempting  vaginal  birth  
after  cesarean    
! Appointment   of   a   qualified   anesthesiologist   to   be   responsible   for   all  
anesthetics  administered  
! Availability   of   a   qualified   physician   with   obstetrical   privileges   to   perform  
operative  vaginal  or  cesarean  delivery  during  administration  of  anesthesia  
! Availability   of   equipment,   facilities,   and   support   personnel   equal   to   that  
provided  in  the  surgical  suite  
! Immediate  availability  of  personnel,  other  than  the  surgical  team,  to  assume  
responsibility  for  resuscitation  of  the  depressed  newborn  
 
Role  of  an  Obstetrician  
! Every   obstetrician   should   be   proficient   in   local   and   pudendal   analgesia   that  
may  be  administered  in  appropriately  selected  circumstances  
! General  anesthesia  should  be  administered  only  by  those  with  special  training    
   
   
1.  Meperidine  and  Promethazine   REGIONAL  ANALGESIA  
• Meperidine  50-­‐100mg  and  Promethazine  25  mg  –  administered  IM  at  intervals    
of  2  to  4  hours     SENSORY  INNERVATION  OF  THE  GENITAL  TRACT  
• More  rapid  effect  if  given  IV  in  doses  of  25  to  50mg  every  1  to  2  hours    
• Meperidine  -­‐    readily  crosses  the  placenta   Uterine  Innervation  
st
• Half-­‐life:  13  hours  or  longer  in  the  newborn   • Pain  during  1  stage  of  labor  –  generated  largely  from  the  uterus  
  • Visceral   sensory   fibers   from   the   uterus,   cervix,   and   upper   vagina   traverse  
2.  Butorphanol  (Stadol)   through  the  Frankenhäuser  ganglion,  which  lies  just  lateral  to  the  cervix,  into  
•  Synthetic  narcotic   the  pelvic  plexus,  and  then  to  the  middle  and  superior  internal  iliac  plexuses.  
•  1-­‐2mg  doses   • Early  in  labor  –  pain  of  uterine  contractions  transmitted  through  the  T11  and  
•  Major  side  effects:  somnolence,  dizziness  and  dysphoria   T12  nerves  
•  Neonatal  respiratory  depression  is  less  than  with  Meperidine   • Motor   pathways   –   leave   the   spinal   cord   at   the   level   of   the   T7     and   T8  
•  Antagonizes  the  narcotic  effects  of  Meperidine     vertebrae  
   
3.  Fentanyl  
•  Short-­‐acting,  very  potent  synthetic  opioid  
•  50-­‐100  µg  intravenously  every  hour  
•  Main  disadvantage:  short  duration  of  action  
 
EFFICACY  AND  SAFETY  OF  PARENTERAL  AGENTS  
1. Meperidine   is   the   most   common   opioid   used   worldwide   for   pain   relief   in  
labor.  
2. There   is   no   convincing   evidence   demonstrating   that   alternative   opioids   are  
better.  
3. There  is  no  evidence  that  parenteral  opioids  influence  the  length  of  labor  or  
need  for  obstetrical  intervention.  
4. Epidural  analgesia  provides  superior  pain  relief.  
   
• Meperidine  or  other  narcotics  –  cause  newborn  respiratory  depression    
 
NARCOTIC  ANTAGONISTS  
 
Naloxone  
•  Capable  of  reversing  respiratory  depression  induced  by  opioid  narcotics  
•  Withdrawal   symptoms   may   be   precipitated   in   recipients   who   are   physically  
dependent  on  narcotics  
•  Contraindicated  in  newborn  of  narcotic-­‐addicted  mother    
 
NITROUS  OXIDE  
• Self-­‐administered   mixture   of   50%   nitrous   oxide   and   oxygen   provides  
satisfactory  analgesia  during  labor  
 
 
 
Lower  Genital  Tract  Innervation   PARACERVICAL  BLOCK  
• Pain  with  vaginal  delivery  arises  from  stimuli  from  the  lower  genital  tract.   • Provides  satisfactory  pain  relief  during  the  first  stage  of  labor  
• Transmitted  primarily  through  the  pudendal  nerve   • Lidocaine   or   Chloroprocaine   5-­‐10mL   is   injected   into   the   cervix   laterally   at   3  
• Pudendal   nerve   –   sensory  nerve  fibers  derived  from  the  ventral  branches  of   and  9  o’clock    
the  S2  through  S4  nerves   • Complication:   fetal  bradycardia  usually  develops  within  10  minutes  and  may  
• Passes   beneath   the   posterior   surface   of   the   sacrospinous   ligament   last  up  to  30  minutes  
just  as  the  ligament  attaches  to  the  ischial  spine    
  SPINAL  (SUBARACHNOID)  BLOCK  
ANESTHETIC  AGENTS   • Advantages:  short  procedure  time,  rapid  onset  of  block,  high  success  rate  
(Table  19-­‐3.  Some  Local  Anesthetic  Agents  used  in  Obstetrics)   ! Vaginal  Delivery  
  •  Popular  form  of  analgesia  for  forceps  or  vacuum  delivery  
Central  Nervous  System  Toxicity   •  Should  extend  to  the  T10  dermatome  
• Early   symptoms   are   those   of   stimulation   but   as   serum   levels   increase   •  Lidocaine  or  Bupivacaine  
depression  follows   ! Cesarean  Delivery  
• Light-­‐headedness,   dizziness,   tinnitus,   metallic   taste   and   numbness   of   the   •  Level  of  sensory  blockade  extending  to  the  T4  dermatome  
tongue  and  mouth   •  10-­‐12  mg  of  hyperbaric  bupivacaine  or  50-­‐75mg    
• Bizarre   behavior,   slurred   speech,   muscle   fasciculation   and   excitation   and   !        of  hyperbaric  Lidocaine  
generalized  convulsions,  followed  by  loss  of  consciousness    
  COMPLICATIONS  OF  SPINAL  (SUBARACHNOID)  BLOCK  
! Cardiovascular  Toxicity   • Hypotension  
! Generally  develop  later  than  those  from  cerebral  toxicity   •  High  spinal  blockade  
! Hypertension   and   tachycardia,   which   is   soon   followed   by   hypotension   and   •  Spinal  (Postural  puncture)  headache  
cardiac  arrhythmias     •  Convulsions  
  •  Bladder  dysfunction  
PUDENDAL  BLOCK   •  Oxytocics  and  hypertension  
• Relatively  safe  and  simple   •  Arachnoiditis  and  meningitis  
• A  tubular  introducer  that  allows  1.0  to  1.5  cm  of  a  15-­‐cm  22-­‐gauge  needle  is    
used  to  guide  the  needle  into  position  over  the  pudendal  nerve   Contraindications  to  Spinal  Anesthesia  
• Complications:   may   cause   serious   systemic   toxicity,   hematoma   formation   ABSOLUTE  CONTRAINDICATIONS  
from  perforation  of  a  blood  vessel   •  Refractory  maternal  hypotension  
  •  Maternal  coagulopathy  
•  Treatment  with  once-­‐daily  dose  of  LMWH  within  12  hours  
•  Untreated  bacteremia  
•  Skin  infection  over  site  of  needle  placement    
•  Increased  intracranial  pressure  caused  by  mass  lesion  
 
EPIDURAL  ANESTHESIA  
Continuous  Lumbar  Epidural  Block  
•  VAGINAL  DELIVERY  -­‐  Block  from  T10  to  S5  dermatomes  
• CESAREAN  DELIVERY  -­‐  Block  extending  from  the  T4  to  S1  dermatomes  
 
 
 
 
COMPLICATIONS  OF  EPIDURAL  ANESTHESIA   EPIDURAL  ANESTHESIA  
• Total  spinal  blockade   Epidural  Opiate  Analgesia  
•  Ineffective  analgesia   • Most  often  given  with  a  local  anesthetic  agent  such  as  bupivacaine    
•  Hypotension   ADVANTAGES  
•  Central  nervous  stimulation   • Rapid  onset  of  pain  relief  
•  Maternal  pyrexia   • Decrease  in  shivering  
•  Back  pain   • Less  dense  motor  blockade  
  SIDE  EFFECTS  
EPIDURAL  ANESTHESIA   • Pruritus  
• Effect  on  Labor   • Urinary  retention  
• Prolongs  active  phase  of  labor  by  1  hour   • Immediate  or  delayed  respiratory  depression  
•  Increases  the  need  for  instrumental  delivery  due  to  prolonged  second-­‐stage    
labor   COMBINED  SPINAL-­‐EPIDURAL  TECHNIQUES  
•  Fetal   Heart   Rate   –   associated   with   improved   neonatal   acid-­‐base   status   • May   provide   rapid   and   effective   analgesia   for   labor   as   well   as   for   cesarean  
compared  with  meperidine   delivery  
•  Cesarean   Delivery   –   Epidural   administration   of   dilute   solutions   of   local   • Needle-­‐through-­‐needle   technique  –   An  introducer  needle  is  first  placed  in  the  
anesthetic  is  less  likely  to  increase  cesarean  delivery  rates  than  concentrated   epidural   space,   then   a   small-­‐gauge   spinal   needle   is   introduced   through   the  
solutions.   epidural  needle  into  the  subarachnoid  space.  
•  Timing   of   epidural   placement   –   women   in   labor   should   not   be   required   to    
reach  4-­‐5cm  of  cervical  dilatation  before  receiving  epidural  analgesia  
 
EPIDURAL  ANESTHESIA  
Safety  
• No  maternal  deaths  
• Very  low  incidence  of  complications  
Contraindications  
• Maternal  hemorrhage    
• Infection  at  or  near  the  sites  of  puncture  
• Suspicion  of  neurological  disease  
• Anticoagulation   –   women   receiving   anticoagulation   therapy   are   at   increased  
risk  for  spinal  cord  hematoma  and  compression      
 
EPIDURAL  ANESTHESIA  
• Severe  Preeclampsia-­‐Eclampsia  
• Most  have  come  to  favor  epidural  blockade  for  labor  and  delivery  in  women    
 
with  severe  preeclampsia  
LOCAL  INFILTRATION  FOR  CESAREAN  DELIVERY  
• Labor   epidural   analgesia   is   to   be   considered   in   women   with   hypertensive  
• To   augment   an   inadequate   or   “patchy”   regional   block   that   was   given   in   an  
disorders,  but  it  is  not  to  be  considered  as  therapy.  
emergency  
• Provided   superior   pain   relief   without   significant   increase   in   maternal   or    
neonatal  complications   st
• 1     -­‐   halfway   between   the   costal   margin   and   iliac   crest   in   midaxillary   line   to  
  block  the  10th,  11th,  and  12th  intercostal  nerves  
  nd
• 2  -­‐  along  the  line  of  proposed  skin  incision  
  rd
• 3  -­‐  at  the  external  inguinal  blocks  the  genitofemoral  and  ilioinguinal  nerves  
 GENERAL  ANESTHESIA  
Preoxygenation  
• Because   functional   reserve   capacity   is   reduced,   pregnant   women   become  
hypoxemic   more   rapidly   during   periods   of   apnea   than   do   nonpregnant  
patients.  
• 100%   oxygen   via   face   mask   for   2-­‐3   minutes   prior   to   anesthesia   induction   to  
replace  nitrogen  in  the  lungs  with  oxygen  
 
INDUCTION  OF  ANESTHESIA  
Thiopental  
• Ease  and  rapid,  with  minimal  risk  of  vomiting  
• Poor  analgesic  agents  
• May  cause  appreciable  newborn  depression  if  given  alone    
Ketamine  
• Used  to  render  patient  unconscious  
• Given  intravenously  in  low  doses  of  0.2  to  0.3  mg/kg  
• Not  associated  with  hypotension  
• Usually  causes  a  rise  in  blood  pressure  
• Unpleasant  delirium  and  hallucinations  are  commonly  induced  by  this  agent.  
 
INTUBATION  
  Succinylcholine    
  • Rapid-­‐onset  and  short-­‐acting  muscle  relaxant  
GENERAL  ANESTHESIA   • Sellick   maneuver   –   Cricoid   pressure   is   used   to   occlude   the   esophagus   from  
PATIENT  PREPARATION   induction  until  intubation    
ANTACIDS    
• Administered  shortly  before  induction  of  anesthesia   FAILED  INTUBATION  
• Sodium  citrate  with  citric  acid  (Bacitra)  30mL  given  45  minutes  before  surgery   • Although  uncommon,  failed  intubation  is  a  major  cause  of  anesthesia-­‐related  
UTERINE  DISPLACEMENT   maternal  mortality.  
• With   lateral   uterine   displacement,   the   duration   of   general   anesthesia   has   less   • A   history   of   previous   difficulties   with   intubation   as   well   as   a   careful  
effect  on  neonatal  condition  than  when  the  woman  remains  supine.   assessment  of  anatomical  features  of  the  neck,  maxillofacial,  pharyngeal,  and  
  laryngeal  structures  may  help  predict  a  difficult  intubation.  
Severe  Preeclampsia-­‐Eclampsia   • Edema   of   the   airway   may   develop   intrapartum   and   present   considerable  
• Most  have  come  to  favor  epidural  blockade  for  labor  and  delivery  in  women   difficulties.  
with  severe  preeclampsia   • Morbid  obesity  is  also  a  major  risk  factor  for  failed  or  difficult  intubation.  
• Labor   epidural   analgesia   is   to   be   considered   in   women   with   hypertensive   • An   important   principle   is   to   start   the   operative   procedure   only   after   it   has  
disorders,  but  it  is  not  to  be  considered  as  therapy.   been   ascertained   that   tracheal   intubation   has   been   successful   and   that  
• Provided   superior   pain   relief   without   significant   increase   in   maternal   or   adequate  ventilation  can  be  accomplished.  
neonatal  complications   • Following   failed   intubation,   the   woman   is   ventilated   by   mask   and   cricoid  
  pressure  is  applied  to  reduce  the  chance  of  aspiration.  
  • Surgery  may  proceed  with  mask  ventilation  or  the  woman  may  be  allowed  to  
  awaken.    
   
GAS  ANESTHETICS   Types  of  Analgesic  and  Sedation  
Volatile  Anesthetics     Effects   Side  Effects  
• Most  commonly  used  is  isoflurane.   Meperidine  50-­‐100mg   Does  not  lead  to   Depressant  effect  in  the  
• Potent  nonexplosive  agent  that  produce  remarkable  uterine  relaxation  when   with  Promethazine  25mg   prolongation  of  labor,   fetus  follows  peak  
given  in  high,  inhaled  concentration   IM  every  3  to  4  hours   rather  an  increase  in   analgesic  affect  in  
USES:   uterine  activity   mother  
• Internal  podalic  version  of  the  second  twin   Butorphanol  1-­‐2mg   Compares  with  40-­‐60mg   Not  given  contiguously  
• Breech  decomposition   of  Meperidine   with  Meperidine,  
• Replacement  of  acutely  inverted  uterus   antagonizes  the  narcotic  
Less  respiratory  
• Occasionally  associated  with  hepatitis  and  massive  hepatic  necrosis   effect  of  Meperidine  
depression  
 
Fentanyl  50-­‐100ug/hr   Safe,  without  effect  on    
Anesthesia  Gas  Exposure  and  Pregnancy  Outcome  
active  phase  of  labor  
• All  anesthetic  agents  that  depress  the  maternal  central  nervous  system  cross  
Nalbuphine  15-­‐20mg  IM   No  neonatal  depression    
the  placenta  and  depress  the  fetal  central  nervous  system.  
or  IV  
• Induction-­‐to-­‐delivery  time  should  be  minimized  
 
 
 
EXTUBATION  
 
• The  tracheal  tube  may  be  safely  removed  only  if  the  woman  is  conscious  to  a  
 
degree   that   enables   her   to   follow   commands   and   is   capable   of   maintaining  
 
oxygen  saturation  with  spontaneous  respiration.  
 
 
 
ASPIRATION  
 
• Aspiration   pneumonitis   has   been   the   most   common   cause   of   anesthetic  
 
deaths  in  obstetrics.  
 
 
 
FASTING  
 
• A   fasting   period   of   8   hours   or   more   is   preferable   for   uncomplicated  
 
parturients  undergoing  elective  cesarean  delivery.  
 
 
 
PATHOPHYSIOLOGY  
 
• The   right   mainstem   bronchus   usually   offers   the   simplest   pathway   for  
 
aspirated   material   to   reach   the   lung   parenchyma,   and   therefore   the   right  
 
lower  lobe  is  most  often  involved.  
 
• The   woman   who   aspirates   may   develop   evidence   of   respiratory   distress  
 
immediately   or   as   long   as   several   hours   after   aspiration,   depending   in   part   on  
 
the  material  aspirated  and  the  severity  of  the  process.  
 
 
 
TREATMENT  
 
• Respiratory  rate  and  oxygen  saturation  as  measured  by  pulse  oximetry  are  the  
 
most  sensitive  and  earliest  indicators  of  injury.  
 
• When   acute   respiratory   distress   syndrome   develops,   mechanical   ventilation  
 
with  positive  end-­‐expiratory  pressure  may  prove  lifesaving.  
 
 
 
General  Anesthesia  
  Route  of   Mechanism  of  Action   Advantages   Disadvantages  
Administration  
Nitrous  Oxide   Inhalation   Alter  the  function  of   Low  potency,  therefore  must  be  combined  with   Produces  analgesia  and  altered  consciousness;  
receptors  for   other  agents;   Risk  of  bone  marrow  depression  due  to  
neurotransmitters,   Rapid  induction  and  recovery;   inhibition  of  Methionine  synthase  with  
nonselectively,  controlling   prolonged  administration    
Good  analgesic  properties;  
the  overall  state  of  
consciousness  and   Does  not  prolong  labor  or  interfere  with  uterine  
response  to  sensory  stimuli   contractions    
Enflurane   Inhalation   Same   Halogenated  anaesthetic  similar  to  halothane;   Some  risk  of  epilepsy-­‐like  seizures  
Less  m etabolism  than  halothane,  therefore  less  
risk  of  toxicity;  
Fast  induction  and  recovery  than  halothane  
(less  accumulation  in  fat)  
Isoflurane   Inhalation   Same   Similar  to  Enflurane,  but  lacks  epileptogenic   Unconsciousness;  
property;   Potential  for  aspiration  in  unprotected  airway;  
May  precipitate  myocardial  ischaemia  in   Crosses  placenta  produce  narcosis  in  the  fetus;  
patients  with  coronary  disease   Produces  uterine  relaxation  in  high  doses  
Halothane   Inhalation   Same   Widely  used  agent   Potential  for  aspiration  in  unprotected  airway;  
Crosses  placenta  produce  narcosis  in  the  fetus;  
Produces  uterine  relaxation  in  high  doses;    
Risk  of  liver  damage  if  used  repeatedly  
 
  Indication   Complications  and  their  Management   Precautions  
Pudendal  block   Provide  analgesia  for  spontaneous  delivery   Intravascular  injection  may  cause   May  not  provide  adequate  analgesia  for  other  
Can  be  used  with  epidural  analgesia  given   serious  toxicity  characterized   than  outlet  delivery  or  when  delivery  requires  
during  labor   extensive  manipulation  
Paracervical  block   Provide  good  to  excellent  pain  relief  during   Fetal  bradycardia,  as  a  consequence  of   Relatively  short  acting,  m ay  have  to  be  repeated  
the  first  stage  of  labor   transplacental  transfer  of  anesthetic   during  labor  
Spinal  (subarachnoid)   For  forceps  and  vacuum  delivery   Hypotension   Disorder  of  coagulation  and  defective  hemostasis  
block   Total  spinal  blockage   preclude  the  use  of  spinal  analgesia  
Spinal  headache  
Convulsions  
Bladder  dysfunction  
Epidural  block   Relief  of  pain  of  uterine  contractions  and   Hypotension   Before  any  injection  of  the  local  anesthetic  agent,  
delivery,  vaginal  or  abdominal   Urinary  retention   a  test  dose  is  given  and  the  women  observed  for  
Cardiorespiratory  arrest   features  of  toxicity  from  intravascular  injection  
and  signs  of  spinal  blockade  form  subarachnoid  
Maternal  pyrexia  
injection  
Back  pain