ANALGESIA IN OBSTETRICS

Introduction :- Labour pain is nature's way of alerting the pregnant mother

about impending childbirth. Relief of pain during labor and delivery is an
essential part in good obstetric care.
 Choice of anesthesia depends upon the patient's conditions and the
associate disorders.
 Anesthetic complications may cause maternal death.
 Anesthesia following full meal may cause maternal death due to vomiting
and aspiration of gastric contents.
What is pain ? ; PAIN :- An unpleasant sensory and emotional experience
associated with actual or potential tissue damage or described in terms of such
damage.
What is labour pain? ; Labor pain :- A recurrent pain felt by a woman during
child birth.
Labor Analgesia:- Obstetric analgesia and anaesthesia has now evolved into
a subspecialty in its own right and the expert obstetric anaesthesiologist
practises the art within the limitations of the pathophysiology of pregnancy and
labour with its accompanying pitfalls and complications. The expert attempts to
strike a balance between the maternal needs of providing adequate pain relief
and the fetal need for safe transition to the neonatal state. It refers to relief of
pain in labor with pharmacological and non-pharmacological methods.
■Anesthesia:-
It refers to complete block of pain sensation with or without loss of
consciousness. This is used during cesarean delivery and for some obstetric
procedures.
Causes of Pain During Labour
Many factors contribute towards the causation of pain during labor:
 Myometrial hypoxia during uterine con- tractions.
 Stretching of the cervix, vagina, vulval orifice and perineum and pressure
on the nerve ganglia innervating the stretched tissues.
 Traction on the serosa of the internal genital organs and traction on the
sup- porting pelvic ligaments.
 Pressure on the bladder, urethra and the rectum and distension of the
muscles of the pelvic floor and perineum.
Effects of Pain on the Obstetric Outcome During Labor
The autonomic changes induced by fear and anxiety resulting from unrelenting
labour pain can cause maternal and fetal acidosis. This does not augur well for a
satisfactory obstetric outcome. Relief of pain during labour has wider
implications than just mitigating pain and rendering labour a more pleasant
experience. Analgesia improves the obstetric outcome by protecting the mother
and her fetus from the ill effects of stress. Good pain relief very often results in
better progress of labour.
Maternal risk factors for anaesthesia are: Short stature, short neck, marked
obesity, severe pre-eclampsia, bleeding disorders, placenta previa, medical
disorders, like cardiac, respiratory and neurological disease.
METHODS OF LABOR ANALGESIA

PHARMACOLOGICAL NONPHARMACOLOGICAL
Pharmacological: 1-local injection use In a highly motivated patients this
may be all that they require-
2-periphral nerve block
relaxation and concentration on
3-regional (epidural, spinal)
breathing ,Massage - including
4-systemic(IV, IM, inhalation) aromatherapy ,Acupuncture and
acupressure, audio analgesia, maternal
5-General anesthesia movement and positioning

Benefits of Pain Relief During Labour

Mother
 Relief from pain, fear and anxiety, and reduces the risk of both
maternal and fetal acidosis.
 Prevents unnecessary and tiresome mus cular activity and
ensures better patient cooperation.
 The labour is shorter and less traumatic, lowers the incidence of
dystocia and there fore decreases the indications for caesar- ean
section.
  Enhances the chances of a safe vaginal delivery with the
maternal satisfaction of accomplishing childbirth herself.
Fetal:- Provides a favorable environment during labour and shorter
labor are less traumatic and less stressful.
 Assures better protection against hypoxia and respiratory
depression, and assures a better long-term outcome.
 Reduces the need for instrumental vaginal delivery.
Obstetrician:-Provides better control over the events during labour
ensuring patient cooperation throughout labour.
 Pressure from the patient and the relatives to intervene is
reduced, ensures satisfactory conditions to prevail during
delivery.
 Helps to avoid many unnecessary obstetric interventions.
ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS
NERVE SUPPLY OF THE GENITAL TRACT:
 Uterus is under both nervous and hormonal control.
 Hypothalamus controls the uterine activity through the reticular formation
which balances the effects of the two autonomic divisions
Motor nerve supply:
 The uterus receives both sympathetic and parasympathetic nerve fibers.
 The sympathetic nerve fibers arise from lower thoracic and upper lumbar
segments of the spinal cord.
 The parasympathetic fibers arise from sacral 2,3 and 4 segments of the
spinal cord.
The pre-ganglionic fibers of the sympathetic nerves arising from
the spinal cord pass through the ganglia of the sympathetic trunk to aortico-
renal plexus where they synapse. The aortico-renal plexus continues as the
superior hypogastric plexus or presacral nerve and passes over the bifurcation of
aorta and divides into right and left hypogastric nerves. Each hypogastric nerve
joins the pelvic parasympathetic nerve of the corresponding side and forms the
pelvic plexus (right and left) or inferior hypogastric plexus. The pelvic plexus
then continues along the course of the uterine artery as paracervical plexus on
each side of the cervix.
Sensory pathway:- Sensory stimuli from the uterine body are transmitted
through the pelvic, superior hypogastric and aortico-renal plexus to the 10th,
11th and 12th dorsal and the first lumbar segments of the spinal cord, Sensory
stimuli from cervix pass through the pelvic plexus along the pelvic
parasympathetic nerves to sacral segments 2, 3 and 4 of the spinal cord Sensory
stimuli from upper vagina pass to 2, 3 and 4 sacral parasympathetic segments
and from lower vagina pass through the pudendal nerve. The perineum receives
both motor and sensory innervation from sacral roots 2, 3 and 4 through the
pudendal nerve. The branches of ilio-inguinal and genital branch of genito-
femoral nerves supply the labia majora and also carry the impulses from the
perineum.
NERVOUS CONTROL OF UTERINE ACTIVITY: Regarding motor
innervation of the uterus, the sympathetic nerves rather than the
parasympathetic have the influences over the uterine activity.
HORMONAL CONTROL:. It is believed that some hormones are essential
for the control of uterine activity. Oxytocin, a hormone derived from posterior
pituitary maintains the uterine activity during labour. Progesterone is the
pregnancy-stabilising hormone. Labour commences when it is withdrawn.
Adrenaline with its beta activity inhibits the contraction of uterus, while its
alpha activity excites it.
METHODS OF COMMONLY USED SEDATIVES AND
PAIN RELIEF ANALGESICS IN LABOUR

Drug Usual dose Frequency Neonatal

Half-life
(Approx.)
(1)
Psychoprophylaxis Pethidine 50-100 mg 4 hr. 13-20 hr.
(2) Sedatives and IM
Analgesics
(3) Inhalation agents 50-100 µg 1 hr. 5 hr.
Fentanyl
(4) Patient controlled
IV
analgesia (PCA)
4 hr.
(5) Transcutaneous
Nalbuphin 10 mg
electric nerve
e (IV/IM) 3 hr.
stimulation (TENS)
6)Regional
10 mg IM 4 hr. 7 hr.
 analgesia
7)General Morphine
anaesthesia

The ideal procedure should produce efficient relief of pain but should
neither depress the respiration of the fetus depress the uterine activity causing
prolonged labour. The drug must be non-toxic and safe for both the mother and
the fetus.

Fetal Consequences of Obstetric Anaesthesia

Antepartum Analgesia / Anaesthesia :-Anesthetic agents
administered to the patient during pregnancy for emergency surgical
procedures, like cervical encirclage, appendectomy. laparotomy for a
twisted ovarian cyst, have the potential for inducing teratogenic
effects, causing an abortion, or predisposing the mother to a preterm
labour. Hence, during the first trimester, many a time if it is possible
to postpone the surgical intervention until after the first trimester is
over by treating the patient conservatively. However in acute surgical
problems, emergency surgery cannot be delayed without jeopardizing
maternal well-being. In such situations the risk of possible pregnancy
termination has to be accepted. The second trimester is a relatively
quiet period of pregnancy. Surgical interventions for conditions that
have the potential for undergoing complications and necessitating
possible surgical intervention with advancing pregnancy are best
tackled in the second trimester. Such conditions include chronic
appendicitis that has shown a tendency to exacerbation, or a freely
mobile ovarian cyst with the potential to undergo torsion or rupture.
Intrapartum Analgesia / Anaesthesia :-Drugs used for obtaining
analgesia or anaesthesia for either pain relief during labour or during
surgical interventions undertaken during delivery are known to cross
the placental barrier and have the potential to adversely affect the
fetus and the newborn. The extent of these adverse effects will be
proportional to the dose of the drug; the time elapsed between drug
administration; and the time of birth, the duration of drug action, and
the gestational maturity of the newborn at the time of delivery.
Respiratory depression and neuro behavioral changes are matters of
concern in the neonate.
Postpartum Analgesia / Anaesthesia :-Postpartum analgesia or
anaesthesia may be required for procedures like postpartum tubal
sterilization, or drugs to secure relief from pain caused by an
episiotomy or to secure sound sleep or relieve anxiety. Drugs given to
the mother are known to be excreted in the breast milk and affect the
infant. However, since they are usually excreted in small amounts,
they generally do not cause much worries, but the clinician must be
always cautious about the possible ill-effects on the baby L 1 Pain in
the second stage of labour additionally involves stretching of the
vagina, pelvic floor, the vulval introitus and the perineum. These
impulses are transmitted through nerves entering S 2 to S4 Agents used
for blocking pain sensation and their placements by various
techniques will be discussed later in the text.
Figure:- Labour Analgesia – depicts the importance of mitigating
pain in labour to achieve maternal, comfort , improved placental
perfusion, shorter labours and better fetal outcome.
OBSTETRIC ANALGESIA
It is a well-known fact that any measure, which relieves pain and
anxiety during labour invariably, favours the dilatation of the cervix
and shortens the duration of labour.
Psychotherapy and Relaxation Techniques
Attendance of a relative or companion and sympathetic hospital staff
present during labour (who provide moral support and
encouragement) helps to soothe the patient and relieves her anxieties.
The progress of labour is better in such patients. Delivery in a water
bath, or on special birthing chairs put the patient in the Centre of all
activity which motivates her better and permits her to assume postures
which keep her most comfortable, Breathing and relaxation exercises
help to divert attention from pain to other activity, which in turn help
to relieve anxiety and improve the progress of labour.
Systemic Drugs, Sedatives and Tranquillizers
Phenothiazines, benzodiazepines and hydroxyzine are used to relieve
anxiety and induce sleep. They synergize well with narcotics.
Commonly used drugs include promethazine (Phenergan) and
diazepam (Calmpose, Valium, Anxol)
SEDATIVES AND ANALGESICS
The following factors are important to control the dose of sedative and
analgesics:
(1) Pain threshold: The threshold of pain varies from patient to patient. Some
patients experience severe pain though the uterine contractions are relatively
weak. In such cases, it is preferable to control the pain adequately.
(2) Parity: The multiparous women need less analgesia due to added relaxation
of the birth canal and rapid delivery.
(3) Maturity of the fetus-Minimal doses of drugs are indicated while the fetus
is thought to be premature to avoid neonatal asphyxia.
For the purpose of selecting a general analgesic drug, labour has been
divided arbitrarily into two phases. The first phase corresponds up to 8 cm
dilatation of the cervix in primigravidae and 6 cm in case of multipara. The
second phase corresponds to dilatation of the cervix beyond the above limits up
to delivery. The first phase is controlled by sedatives and analgesics and the
second phase is controlled by inhalation agents. The idea is to avoid the risk of
delivery of a depressed baby.
OPIOID ANALGESICS- 1) Pethidine: For a long time pethidine has been
used as an analgesic in labour. It has got strong sedative but less analgesic
efficacy. Pethidine is generally used in the first phase of labour and indicated
when the discomfort of labour merges into regular, frequent and painful
contractions.
Dose:- 100 mg in 2 ml amp (Haffkine/Neon Lab) is 100 mg (1.5 mg/kg body
wt) IM and repeated as the effect of the first dose begins to wane, without
waiting for the re-establishment of labour pain. Hospitals and Nursing homes
must have their own license to procure it and strict accounting is required.
Dose 100 mg 6-8 hourly IM (1.5 mg/kg body wt) on demand. If the
patient is having excrutiating pain-25 mg may be given IV for instant relief and
the rest 75 mg IM.
side effects:- pethidine to the mother are nausea, vomiting, delayed gastric
emptying. Ranitidine should be given to inhibit gastric acid production and
emetic effect is counteracted by metoclopramide (10 mg IM). Pethidine crosses
the placenta and accumulates in fetal tissues. Pethidine depresses respiration
and suckling of the new born when administered before delivery.
Caution: In primigravida, it is to be avoided if dilatation has reached & cm and
in multi if it has reached 6 cm to avoid the risk of respiratory depression in
neonate at birth. In addition to neonatal respiratory depression, it also causes
gastric stasis in the mother (British National Formulary, 2004).
Meptazinol has got similar analgesic and sedative property as that of pethidine.
It causes less respiratory depression of the new born.
2)Fentanyl is a short acting synthetic opioid and is equipotent to
pethidine. It has less neonatal effects and less maternal nausea and vomiting. It
needs frequent dosing.
3)Pentazocin :- analgesic 30 mg in 1 ml amp Fortwin (Ranbaxy); Zocin .
Dose 30 mg 6 hourly IM. It can also be given in half dose (15 mg) IV slowly
for quicker onset of action relief.
4)Tramadol :-50 mg in ml amp Contramal (SSPL); Tramnazac (Zydus)
Dose 50 to 100 mg IM6 hourly as required. It can also be given IV slowly.
Advantage It does not cause depression of fetal respiratory center and hence
safer for the baby.
5)Phenothiazines: Promethazine (phenargan) is commonly used in labour in
combination with an opioid. It does not cause major neonatal depression.
Promethazine is a weak antiemetic drug and causes sedation in the mother.
Narcotic antagonists are used to reverse the respiratory depression
induced by opioid narcotics. Naloxone is given to the mother 0.4 mg IV in
labour. It may have to be repeated. It is given to the newborn 10 µg/kg IM or IV
and is repeated if necessary when the infant is born with narcotic depression.
Naloxone is given to a newborn born of a narcotic addicted mother. with proper
ventilation arrangement only otherwise withdrawal symptoms are precipitated.
6)TRANQUILISERS-Benzodiazepines (Diazepam): It is well tolerated by
the patient. It does not produce vomiting and helps in the dilatation of cervix. It
is metabolised in the liver. The usual dose is 5-10 mg. It may be used in larger
doses in the management of pre- eclampsia. However, diazepam is avoided in
labour. Major disadvantages are: Loss of beat to beat variability in labour,
neonatal hypotonia and hypothermia. Flumazenil is a specific benzodiazepine
antagonist. It can reverse the respiratory depression effect of benzodiazepines.
Combination of narcotics and antiemetics: Narcotics may be used in
combination with promethazine, metoclopramide or ondansetron. The
advantages claimed that the combination potentiates the action of narcotic,
produces less respiratory depression and prevents vomiting. But there are also
disadvantages like hypotension and delay of second stage of Labour.
 PROMETHAZINE HCL inj 25 mg
Phenergan (Nic Piramal); Phena (Ind Swift)
This is not an analgesic but when given in combination with pethidine or
pentązocin in the dosage of 25 mg IM it potentiates their action as a result of
which patient gets more complete pain relief. Besides, its addition may allow
reduction of dose of Pethidine thereby reducing the risk of neonatal depression.
Dissociative Analgesia
Phencyclidine (ketamine, Ketalar) can be used effectively to provide intense
maternal analgesia and induce sleep without loss of consciousness. Diazepam is
also administered concomitantly to control undesirable psychomimetic side
effects like hallucinations.
Transcutaneous Electrical Nerve Stimulation (TENS)
Experience with this form of analgesia during labour has received mixed
reception. Relief considerable but may fall short of being optimal The need for
additional use of narcotic drugs definitely reduced. The greatest advantage lies
in the fact that it does not interfere in any way with the mother, fetus, newborn
baby or the course of labour.
 INHALATION METHODS
It is usually breathed through a mouthpiece or a mask, which ever you prefer.
Ideally, it is not used for long periods of time as it can be dehydrating.
Nitrous oxide and air: Nitrous oxide has minimal effect on the fetus and does
not interfere with uterine contraction. This agent is used in the second phase
(from three quarter dilatation of cervix to delivery). Now-a-days, nitrous oxide
and air this mixture produces hypoxia.
Premixed nitrous oxide and oxygen: Cylinders contain 50 percent nitrous
oxide and 50 percent oxygen mixture. Entonos apparatus has been approved for
use by midwives. It can be self administered. Entonox is most commonly used
inhalation agent during labour in U.K. Hyperventilation, dizziness, hypocapnia
are the side effects.
Trichloroethylene (Trilene): This is an useful drug in labour with high
analgesic effect. It gives better results in nervous and high strung women than
nitrous oxide. It is no longer used these days.
Methoxy flurane, Isoflurane, Enflurane: They are good analgesic agents and
more effective than trichloroethylene. However, advantages over nitrous oxide
are marginal.

Regional anaesthesia
The methods so far considered cannot ensure a painless delivery nor can they
make labour tolerable when the pain is very severe. When complete relief of
pain is needed throughout labour, epidural analgesia is the safest and simplest
method for procuring it. But anaesthetists/obstetrician have to be trained
properly to make use of this very valuable method in normal and abnormal
labour.
Paracervical nerve block : Is useful for pain relief during the first stage of
labour. Following the usual antiseptic safe guards. a long needle (15 cm or
more) is passed into the lateral fornix, at the three and nine o'clock positions. 5-
10 ml of 1 per lignocaine with adrenaline are injected at the site of the cervix
and the procedure is repeated on the other side. This dose is quite sufficient to
relieve pain for about an hour or two, and injections can be given more than
once if necessary. Bupivacaine is avoided due to its cardiotoxicity Paracervical
block should not be used where placental insufficiency is present. In order to
avoid complications, a specially constructed guard tube is used. A needle is
inserted through the tube and is of such a length that it protrudes not more than
7 mm beyond its tip.
Caudal Block :-The caudal space is the most inferior extension of the
epidural space. Local anaesthetic is injected through the sacral hiatus into this
space in the caudal canal. The extent of anaesthesia depends on the volume of
drug inject In general procedures requiring block up to T 10 levels can be
accomplished
The disadvantages include lack of availability of adequate expertise,
accidental injury to the fetal scalp and head. Relaxation of the levator muscular
sling interferes with the rotation of the fetal head, and relaxation of the perineal
sphincters causes faecal incontinence and contamination of the perineal area.
Hence caudal anaesthesia is not much preferred in the present day practice.

Continuous lumbar epidural block: A lumbar puncture is made between

L2 and L3 with the epidural needle (Tuohy needle). With the patient on her left
side, the back of the patient is cleansed with antiseptics before injection. When
the epidural space is ensured, a plastic catheter is passed through the epidural
needle for continuous epidural analgesia. A local anaesthetic agent is injected
into the epidural space. Full dose is given after a test dose when there is no
toxicity. For complete analgesia a block from T10 to the S5 dermatomes is
needed. For caesarean delivery a block from T4 to S1 is needed. Repeated doses
(top ups) of 4 to 5 ml of 0.5 percent bupivacaine or 1 percent lignocaine are
used to maintain analgesia. Epidural analgesia, as a general rule should be given
when labour is well established. Maternal hydration should be adequate with
normal saline or Hartmann's solution (crystalloid) infusion prior commencing
the blockade. The patient's blood pressure, pulse and the fetal heart rate should
be recorded at 15 minutes interval following the induction of analgesia and
hypotension, if occurs, should be treated immediately. The women is kept in
semi-lateral position to avoid aorto-caval compression.

Pudendal nerve block does not relieve the pain of labour but affords perineal
analgesia and relaxation. Pudendal nerve block is mostly used for forceps and
vaginal breech delivery. Simultaneous perineal and vulval infiltration is needed
to block the perineal branch of the posterior cutaneous nerve of the thigh and
the labial branches of the ilio-inguinal and genito-femoral nerves (vide supra).
This method of analgesia is associated with less danger, both for the mother and
for the baby than general anaesthesia.
Complications: Haematoma formation, infection and rarely intravascular
injection.
Advantages of regional anaesthesia
 The patient is awake and can enjoy the birth time.
 Newborn Apgar score generally good.
 Lowered risk of maternal aspiration.
 Post operative pain control is better.
CONTRAINDICATIONS OF EPIDURAL ANALGESIA
 Maternal coagulopathy or anticoagulant therapy
 Supine hypotension
 Hypovolemia
 Neurological diseases
 Spinal deformity or chronic low back pain
COMPLICATIONS OF EPIDURAL ANALGESIA
 Hypotension due to sympathetic blockade. Parturient should be well
hydrated with (IL) crystalloid solution before hand.
 Pain at the insertion site. Back pain.
 Post spinal headache due to leakage of cerebrospinal fluid through the
needle hole in the dura.
 Total spinal due to inadvertent administration of the drug in the
subarachnoid space.
 Injury to nerves, convulsions, pyrexia.
 Ineffective analgesia.
Spinal anaesthesia: Spinal anaesthesia is obtained by injection of local
anaesthetic agent into the subarachnoid has less procedure time and high
success rate. Spinal anaesthesia can be employed to alleviate the pain of
delivery and during the third stage of labour. For normal delivery or for outlet
forceps with episiotomy, ventouse delivery, block should extend from T10
(umbilicus) to St. For caesarean delivery level of sensory block should be up to
14 dermatome. Hyperbaric bupivacaine (10-12 mg) or lignocaine (50-70 mg) is
used. Addition of fentanyl (to enhance the onset of block) at morphine to
improve pain control) may be done, Brief or minimal spinal anaesthesia is far
safer than prolonged spinal anaesthesia. The advantages of spinal anaesthesia
are (a) less fetal hypoxia unless there is hypotension and (b) mi- nimal blood
loss. The technique is not difficult and no inhalation anaesthesia is required, but
post spinal headache occurs in 5-10 per cent of patients.
SIDE EFFECTS OF SPINAL ANAESTHESIA
 Hypotension due to blocking of sympathetic fibres leading to
vasodilatation and low cardiac output
 Respiratory depression may occur
 Failed block, chemical menengitis, epidural abscess
 Total spinal due to excessive dose or improper positioning
 Postspinal headache-due to low or high CSF pressure and leakage of CSF
 Meningitis due to faulty asepsis
 Transient or permanent paralysis
 Toxic reaction of local anaesthetic drugs
 Paralysis and nerve injury
 Nausea and vomiting are not uncommon
 Urinary retention (bladder dysfunction).
Combined spinal-epidural analgesia: An introducer needle is first
placed in the epidural space. A small gauge spinal needle is introduced through
the epidural needle into the subarachnoid space (needle through needle
technique). A single bolus of 1 ml 0.25% bupivacaine with 25 µg fentanil is
injected into the sub-arachnoid space. The spinal needle is then withdrawn. An
epidural catheter is thus sited for repeated doses of anaesthetic drug. The
method gives rapid and effective analgesia during labour and caesarean
delivery.
INFILTRATION ANALGESIA

Perineal infiltration: For episiotomy-Perineal infiltration anaesthesia is

extensively used prior to episiotomy. A 10 ml syringe, with a fine needle and
about 8-10 ml 1% lignocaine hydrochloride (Xylocaine) are required. The
perineum on the proposed episiotomy site is infiltrated in a fan-wise manner
starting from the middle of the fourchette. Each time prior to infiltration,
aspiration to exclude blood is mandatory. Episiotomy is to be done about 2-5
minutes following infiltration.
For outlet forceps or ventouse (Perineal and labial infiltration): The
combined perineal and labial infiltration is effective in outlet forceps operation
or ventouse traction.
Local abdominal for caesarean delivery: This method is rarely used where
regional block is patchy or inadequate. Technique: The skin is infiltrated along
the line of incision with diluted solution of lignocaine (2%) with normal saline.
The subcutaneous fatty layer, muscle, rectus sheath layers are infiltrated as the
layers are seen during operation. The operation should be done slowly for the
drug to become effective.
PATIENT CONTROLLED ANALGESIA (PCA): Narcotics are
administered by the mother herself from a pump at continuous or intermittent
demand rate through intravenous route. Total dose is limited as there is a
lockout interval. This offers better pain control than high doses given at a long
interval by the midwife. Maternal satisfaction is high with this method.
Drugs commonly used are pethidine, meperidine or Fentanyl.
PSYCHOPROPHYLAXIS (Syn: Natural child birth): It is psychological
method of antenatal preparation designed to Prevent or at least to minimize pain
and difficulty during labour. For most women, labour is a time of apprehension,
fear and agony. As a result of suitable antenatal preparation, majority of women
have labour that is easy and painless.

GENERAL ANAESTHESIA FOR CAESAREAN SECTION

The following are the important considerations of general anaesthesia for
caesarean section:
 Caesarean section may have to be done either as an elective or emergency
procedure.
 A fasting of 6-8 hours is preferable for an elective surgery.
 The mother may have a full stomach raising the probability of aspiration
 A large number of drugs pass through the placental barrier and may
depress the baby.
 Uterine contractility may be diminished by volatile anaesthetic agents
like ether, halothane.
  Lateral tilt of the women during operation. Halothane, isoflurane cause
cardiac depression, hepatic necrosis and hypotension.
 Hypoxia and hypercapnia may occur.
 Time interval from uterine incision to delivery is related directly to fetal
acidosis and hypoxia Longer the exposure to general anaesthetic before
delivery the more depressed is the Apgar score.
Complications of general anaesthesia: Aspiration of gastric contents
(Mendelson's syndrome) is a serious and life threatening one. Delayed gastric
emptying due to high level of serum progesterone, decreased motilin and
maternal apprehension during labour is the predisposing factor.