OBSTETRICAL ANALGESIA AND A

NESTHESIA
EPIDURAL ANALGESIA

Lee, Hyeonjeong
EPIDURAL ANALGESIA
 Injection of a local anesthetic agent into the epid
ural or peridural space to relief of labor and child
birth pain
 Entry for the obstetrical analgesia is through a lu
mbar intervertebral space
 Indwelling catheter is placed for subsequent agen
t administration or continuous infusion
CONTINUOUS LUMBAR EPIDURAL BLOC
K
 Vaginal delivery: Block from T10 to S5 dermatom
es
 Cesarean delivery: Block extending from the T4 to
S1 dermatomes is desired
 The effective of spread of anesthetic depends on:
─ Catheter tip location
─ Dose
─ Concentration
─ Volume of anesthetic agent used
─ Mother is head-down, horizontal, or head-up
COMPLICATIONS OF EPIDURAL ANESTH
ESIA
 Total spinal blockade
• Dural puncture with inadvertent subarachnoid injection
 Ineffective analgesia
 Hypotension
 Sympathetic blockade from analgesic agent cause hypot
ension and decreased cardiac output
 In normal pregnancy, hypotension can be prevented by r
apid infusion of 500 to 1000mL of crystalloid solution
 Central nervous stimulation
 Convulsions are an uncommon but serious complicatio
n, immediate management is needed
COMPLICATIONS OF EPIDURAL ANESTH
ESIA (CONT’)
 Maternal Fever
2 general theories concerning the etiology are matern
al-fetal infection or dysregulation of body temperatur
e
 Back pain
 Miscellaneous complications
A spinal or epidural hematoma (rare)
 Epidural abscesses (rare)
EFFECT ON LABOR
 Epidural analgesia prolongs labor and increases t
he use of oxytocin stimulation
 Epidural analgesia prolonged the active phase of l
abor by 1 hour
 Epidural analgesia also increased the need for op
erative vaginal delivery because of prolonged sec
ond-stage labor without adverse neonatal effects
 This association between epidural analgesia and
prolonged second-stage labor as well as operativ
e vaginal delivery has been attributed to local-ane
sthetic induced motor blockade and resultant imp
aired maternal expulsive efforts
 Fetal heart rate
 Associated
with improved neonatal acid-base status c
ompared with meperidine
 Cesarean delivery rate
 Concluded that epidural analgesia is not associated w
ith an increased cesarean delivery rate
 Timing of Epidural Placement
 Epidural placement in early labor was linked to an incr
ease risk of cesarean delivery
 Women in labor should not be required to reach 4 to
5cm of cervical dilation before receiving epidural anal
gesia
 Safety
 There was no maternal deaths
 Very low incidence of complications

 Contraindications
 Maternal hemorrhage
 Infection at or near the puncture site
 Suspicion of neurological disease

1. Thrombocytopenia
2. Anticoagulation
 Women receiving anticoagulation therapy are at increased ri
sk for spinal cord hematoma and compression
 Severe preeclampsia-eclampsia
 Most have come to favor epidural blockade for labor and de
livery in women with severe preeclampsia
 Labor epidural analgesia was safe in women with hypertensi
ve disorders
 Epidural opiate analgesia
 Most often are given with a local anesthetic agent such as b
upivacaine
 Major advantages
 Rapid onset of pain relief
 Decrease in shivering

 Less dense motor blockade

 Side effects are common and include pruritus and urinary retention

 Naloxone, given intravenously, will abolish symptoms witho

ut affecting the analgesic action
COMBINED SPINAL-EPIDURAL TECHNIQ
UES
 May provide rapid and effective analgesia for lab
or and for cesarean delivery
 Needle-through-needle technique
 The introducer needle is first placed in the epidural sp
ace
 A small-gauge spinal needle is then introduced throu
gh the epidural needle into the subarachnoid space
 The spinal needle is withdrawn, and an epidural catheter is t
hen placed through the introducer needle
 A subarachnoid opioid bolus results in the rapid onset of pr

ofound pain relief with no motor blockade

 The epidural catheter permits repeated analgesia dosing
LOCAL INFILTRATION FOR CESAREAN DE
LIVERY
 A local block is useful to augment an inadequate
or “patchy” regional block that was given emerge
ntly
 First injection site: halfway between the costal m
argin and iliac crest in the midaxillary line to block
the 10th, 11th, 12th intercostal nerves
 A second injection at the external inquinal ring bl
ocks branches of the genitofemoral and ilioinguin
al nerves (infiltrated bilaterally)
 A final site is along the line of proposed skin incisi
on
GENERAL ANESTHESIA
:PATIENT PREPARATION
 Antacid administration
 To decrease mortality rates from general anesthesia
 Uterine displacement
 Theduration of general anesthesia has less effect on
neonatal condition than if the woman remains supin
e
 Preoxygenation
 To minimize hypoxia
 Pregnant woman become hypoxemic more rapidly du
ring periods of apnea than do nonpregnant patients
because functional reserve lung capacity is reduced
 Administrating 100-percent oxygen via face mask for
2 to 3 minutes before anesthesia induction
: INDUCTION OF ANESTHESIA
 Thiopental
 Given intravenously was used and offered easy and rapid in
duction, prompt recovery, and minimal risk of vomiting
 Unfortunately, this thiobarbiturate is no longer available

 Drug now being used in lieu of thiopental include pro

pofol or etomidate. Propofol has the undesirable side
effect of hypotension
 Ketamine
 Used to render a patient unconscious
 1 mg/kg induce general anesthesia
 Causes a rise in blood pressure
 Should be avoided in women who are already hypertensive
 Unpleasant delirium and hallucinations are commonly indu
ced
: INTUBATION
 Immediately after patient is rendered unconsciou
s, a muscle relaxant is given to aid intubation
 Succinylcholine, a rapid-onset and short-acting ag
ent is used
 Cricoid pressure-the Sellick maneuver-is applied t
o occlude the esophagus from the induction until
intubation is completed
: INTUBATION
 Failed intubation
 Failed intubation is a major cause of anesthesia-relate
d maternal mortality
 A history of prior difficult intubation and a careful ana
tomical assessment of the neck and the maxillofacial,
pharyngeal, and laryngeal structure may help predict i
ntubation complications
 Edema may develop intrapartum and present conside
rable challenges
 Morbid obesity is also a major risk factor for failed or
difficult intubation
: INTUBATION
 Management
 To startthe operative procedure only after it has been
ascertained that tracheal intubation has been successf
ul and that adequate ventilation can be accomplished
 Following failed intubation, the women is ventilated b
y mask and cricoid pressure is applied to reduce the a
spiration risk
 Surgery may proceed with mask ventilation or the wo
man may be allowed to awaken
: GAS ANESTHETICS
 Volatile halogenated agent is added to provide a
mnesia and additional analgesia
 The most commonly used volatile anesthetics incl
ude isoflurane and two of its derivatives, desflura
ne and sevoflurane
 They are potent, nonexplosive agents that produc
e remarkable uterine relaxation when given in hig
h concentration
: EXTUBATION
 The endotracheal tube may be safely removed onl
y if the woman is conscious to a degree that enab
les her to follow commands and is capable of mai
ntaining oxygen saturation with spontaneous res
piration
: ASPIRATION
 Massive gastric acidic inhalation may cause pulm
onary insufficiency from aspiration pneumonitis
 Aspiration pneumonitis has been the most comm
on cause of anesthetic deaths in obstetrics
 To minimize the risk, antacids should be given rou
tinely, intubation should be accompanied by crico
id pressure, and regional analgesia should be em
ployed when possible
: ASPIRATION
 Fasting
A fasting period of 6 to 8 hours is recommended for uncomplic
ated parturients undergoing elective cesarean delivery

 Pathophysiology
 The right mainstem bronchus usually offers the simplest pathw
ay for aspirated material to reach the lung parenchyma, and the
refore, the right lower lobe is most often involved
 The woman who aspirates may develop evidence of respiratory
distress immediately or several hours after aspiration, dependin
g in part on the material aspirated and the severity of response
 When highly acidic liquid is inspired, decreased oxygen saturati
on along with tachypnea, bronchospasm, rhonchi, rales, atelect
asis, cyanosis, tachycardia and hypotension are likely to develop
 Treatment
 Respiratory rate and oxygen saturation as measured by pu
lse oximetry are the most sensitive and earliest indicators
of injury
 Inhaled fluid should be immediately and thoroughly wipe
d from the mouth and removed from the pharynx and tra
chea by suction
 Large particulate matter is inspired, bronchoscopy may be
indicated to relieve airway obstruction
 There is no convincing clinical or experimental evidence th
at corticosteroid therapy or prophylactic antimicrobial ad
ministration is beneficial
 When acute respiratory distress syndrome develops, mech
anical ventilation which positive end-expiratory pressure
may prove lifesaving
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