ANESTHESIA(AND(ANALGESIA! !

Far Eastern University

Dr. Nicanor Reyes Medical Foundation Department of Obstetrics and Gynecology

MATERNAL! RISK! FACTORS! THAT! SHOULD! PROMPT! ANESTHESIA! CONSULTATION: 1.!Marked!Obesity 2.!Severe!edema!or!anatomical!abnormaliGes!of!face,!neck,!or!spine,!! !!!!!including!trauma!or!surgery 3.!Abnormal!denGGon,!small!mandible,!or!diculty!opening!mouth 4.!Extremely!short!stature!,!short!neck,!or!arthriGs!of!the!neck 5.!Goiter 6.!Serious!maternal!medical!problems,!such!as!cardiac,!pulmonary!or!!!! !!!!!neurological!disease 7.!Bleeding!disorders 8.!Severe!preeclampsia 9.!Previous!history!of!anestheGc!complicaGons 10.!Obstetrical!complicaGons!likely!lead!to!operaGve!delivery!!! !!!!!!!e.g.,!placenta!previa!or!higher[order!mulGple!gestaGon

Goals(for(Op4mizing(Obstetrical( Anesthesia(Services((

! Availability! of! a! licensed! pracGGoner! who! is! credenGaled! to! administer!an!appropriate!anestheGc!whenever!necessary!and!to! maintain!support!of!vital!funcGons!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!acGve!labor!of!a!woman ! a^empGng!vaginal!birth!a_er!cesarean!! Appointment! of! a! qualied! anesthesiologist! to! be! responsible ! for!all!anestheGcs!administered!

Goals(for(Op4mizing(Obstetrical(Anesthesia(Services((

Goals(for(Op4mizing(Obstetrical(Anesthesia(Services((
Availability! of! a! qualied! physician! with! obstetrical ! privileges! to! perform! operaGve! vaginal! or! cesarean ! delivery!during!administraGon!of!anesthesia! A vailability! of! equipment,! faciliGes,! and! support ! personnel!equal!to!that!provided!in!the!surgical!suite! Immediate! availability! of! personnel,! other! than! the ! surgical!team,!to!assume!responsibility!for!resuscitaGon!of ! the!depressed!newborn!

Principles(of(Pain(Relief!

Principles(of(Pain(Relief!
Labor! pain! is! a! highly! individual! reecGon! of! variable! sGmuli.! These! sGmuli! are! modied! by! emoGonal,! moGvaGonal, ! cogniGve,!social,!and!cultural!circumstances! Choice!among!a!variety!of!methods!and!individualizaGon ! of!pain!relief!is!desirable! (

Nonpharmacological(Methods(of(( Pain(Control!

Nonpharmacological(Methods(of(Pain(Control!
1.(LAMAZE( Pain!o_en!can!be!lessened!by!teaching!pregnant!women!relaxed! breathing! and! their! labor! partners! psychological! support! techniques.! The!presence!of!a!supporGve!spouse!or!other!family!member,!of ! conscienGous!labor!a^endants,!and!of!a!considerate!obstetrician ! who!insGlls!condence,!have!all!been!found!to!be!of!considerable ! benet.! ! 2.( CLINICAL( HYPNOSIS( ( power! of! the! mind! to! heal! the! body; ! increases!of!beta!endorphins!in!the!peripheral!blood! ( 3.(ACUPUNCTURE(

PARENTERAL(AGENTS(

PARENTERAL(AGENTS(
( 1.(Meperidine(and(Promethazine( ( Meperidine( 50[100mg! and! Promethazine! 25! mg! ! administered!intramuscularly!at!intervals!of!2!to!4!hours!! More!rapid!eect!if!given!intravenously!in!doses!of!25!to ! 50mg!every!1!to!2!hours! Meperidine()((readily!crosses!the!placenta! HalfMlife:(13!hours!or!longer!in!the!newborn!

PARENTERAL(AGENTS(
2.(Butorphanol((Stadol)( ( !SyntheGc!narcoGc! (1M2mg!doses! (Major(side(eects:!somnolence,!dizziness!and!dysphoria! !Neonatal!respiratory!depression!is!less!than!with!! !!!Meperidine! !Antagonizes!the!narcoGc!eects!of!Meperidine!! ( 3.(Fentanyl( ( !Short[acGng,!very!potent!syntheGc!opioid! (50M100(g!intravenously!every!hour! (Main(disadvantage:!short!duraGon!of!acGon!

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! demonstraGng! that ! alternaGve!opioids!are!be^er.! 3.There! is! no! evidence! that! parenteral! opioids! inuence! the ! length!of!labor!or!need!for!obstetrical!intervenGon.! 4.Epidural!analgesia!provides!superior!pain!relief.! Meperidine( or( other( narco4cs! ! cause! newborn! respiratory ! depression!

NARCOTIC(ANTAGONISTS(
( Naloxone(
( ! Capable! of! reversing! respiratory! depression! induced! by! opioid!narcoGcs! !Withdrawal!symptoms!may!be!precipitated!in!recipients!who! are!physically!dependent!on!narcoGcs! !Contraindicated!in!newborn!of!narcoGc[addicted!mother!! ( NITROUS(OXIDE( ( Self[administered! mixture! of! 50%! nitrous! oxide! and! oxygen! provides!saGsfactory!analgesia!during!labor!

REGIONAL(ANALGESIA!

SENSORY(INNERVATION(OF(THE(GENITAL(TRACT( ( Uterine(Innerva4on(
(

Pain! during! 1st! stage! of! labor! ! generated! largely! from! the! uterus! Visceral! sensory! bers! from! the! uterus,! cervix,! and! upper ! vagina! traverse! through! the! Frankenhuser! ganglion,! which ! lies!just!lateral!to!the!cervix,!into!the!pelvic!plexus,!and!then ! to!the!middle!and!superior!internal!iliac!plexuses.! Early( in( labor( ( pain! of! uterine! contracGons! transmi^ed ! through!the!T11!and!T12!nerves! Motor(pathways(!leave!the!spinal!cord!at!the!level!of!the!T7 ! and!T8!vertebrae!

Motor:!! T7!&!T8!

Early! labor:!! T11!!T12!

Lower(Genital(Tract(Innerva4on( ( Pain!with!vaginal!delivery!arises!from!sGmuli!from!the!lower ! genital!tract.! Transmi^ed!primarily!through!the!pudendal(nerve( Pudendal( nerve( ( sensory! nerve! bers! derived! from! the ! ventral!branches!of!the!S2!through!S4!nerves! Passes!beneath!the!posterior!surface!of!the!sacrospinous ! ligament!just!as!the!ligament!a^aches!to!the!ischial!spine!

ANESTHETIC(AGENTS(

(Table(19)3.(Some(Local(Anesthe@c(Agents(used(in(Obstetrics)(

( Central(Nervous(System(Toxicity( ( Early! symptoms! are! those! of! sGmulaGon! but! as! serum! levels!increase!depression!follows! Light[headedness,! dizziness,! Gnnitus,! metallic! taste! and ! numbness!of!the!tongue!and!mouth! Bizarre!behavior,!slurred!speech,!muscle!fasciculaGon!and ! excitaGon!and!generalized!convulsions,!followed!by!loss!of ! consciousness! (

Cardiovascular(Toxicity( ( Generally! develop! later! than! those! from ! cerebral!toxicity! Hypertension! and! tachycardia,! which! is! soon ! followed! by! hypotension! and! cardiac ! arrhythmias!!

PUDENDAL(BLOCK(

( RelaGvely!safe!and!simple! 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!posiGon!over!the!pudendal!nerve! Complica4ons:( may! cause! serious! systemic ! toxicity,! hematoma! formaGon! from! perforaGon ! of!a!blood!vessel!

PARACERVICAL(BLOCK(

( Provides! saGsfactory! pain! relief! during! the! rst ! stage!of!labor! Lidocaine( or( Chloroprocaine! 5M10mL! is! injected ! into!the!cervix!laterally!at!3!and!9!o clock!! C omplica4on:( fetal! bradycardia! usually ! develops!within!10!minutes!and!may!last!up!to!30 ! minutes!

SPINAL((SUBARACHNOID)(BLOCK(

( ( Advantages:( short! procedure! Gme,! rapid! onset! of! block,! high!success!rate! ( Vaginal(Delivery( ( !Popular!form!of!analgesia!for!forceps!or!vacuum!delivery! !Should!extend!to!the!T10!dermatome! (Lidocaine(or!Bupivacaine! ( Cesarean(Delivery( ( !Level!of!sensory!blockade!extending!to!the!T4!dermatome! (10M12(mg!of!hyperbaric!bupivacaine!or!50M75mg!! !!!!of!hyperbaric!Lidocaine!

COMPLICATIONS(OF(SPINAL((SUBARACHNOID)(BLOCK(
!

!Hypotension! !High!spinal!blockade! !Spinal!(Postural!puncture)!headache! !Convulsions! !Bladder!dysfuncGon! ! !Oxytocics!and!hypertension! !ArachnoidiGs!and!meningiGs!

Contraindica4ons(to(Spinal(Anesthesia( ( ABSOLUTE(CONTRAINDICATIONS( ( !Refractory!maternal!hypotension! !Maternal!coagulopathy! !Treatment!with!once[daily!dose!of!low[molecular[!! !!!!weight!heparin!within!12(hours( !Untreated!bacteremia! !Skin!infecGon!over!site!of!needle!placement!! ! Increased! intracranial! pressure! caused! by! mass! lesion!

EPIDURAL(ANESTHESIA(

( Con4nuous(Lumbar(Epidural(Block( ( (vaginal(delivery![!Block!from!T10!to!S5!dermatomes! cesarean(delivery![!Block!extending!from!the!T4!to!S1!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!dermatomes!is!desired! (

COMPLICATIONS(OF(EPIDURAL(ANESTHESIA(
!

!Total!spinal!blockade! !IneecGve!analgesia! !Hypotension! !Central!nervous!sGmulaGon! !Maternal!pyrexia! !Back!pain!

EPIDURAL(ANESTHESIA(
Eect(on(Labor(
( !Prolongs!acGve!phase!of!labor!by!1!hour! ! Increases! the! need! for! instrumental! delivery! due! to! prolonged! second[ stage!labor! ! Fetal! Heart! Rate! ! associated! with! improved! neonatal! acid[base! status ! compared!with!meperidine( ! Cesarean! Delivery! ! Epidural! administraGon! of! dilute! soluGons! of! local ! anestheGc! is! less! likely! to! increase! cesarean! delivery! rates! than ! concentrated!soluGons.! !Timing!of!epidural!placement!!women!in!labor!should!not!be!required!to ! reach!4[5cm!of!cervical!dilataGon!before!receiving!epidural!analgesia!

EPIDURAL(ANESTHESIA(
Safety( ( No!maternal!deaths! Very!low!incidence!of!complicaGons! ( Contraindica4ons( ( !Maternal!hemorrhage!! !InfecGon!at!or!near!the!sites!of!puncture! !Suspicion!of!neurological!disease! !AnGcoagulaGon!!women!receiving!anGcoagulaGon!therapy!! !!!are!at!increased!risk!for!spinal!cord!hematoma!and!compression!!!

EPIDURAL(ANESTHESIA(
Severe(PreeclampsiaMEclampsia( ! Most!have!come!to!favor!epidural!blockade!for!labor!and!delivery!in! women!with!severe!preeclampsia! Labor! epidural! analgesia! is! to! be! considered! in! women! with ! hypertensive!disorders,!but!it!is!not!to!be!considered!as!therapy.( Provided! superior! pain! relief! without! signicant! increase! in ! maternal!or!neonatal!complicaGons!

EPIDURAL(ANESTHESIA(
Epidural(Opiate(Analgesia( ( Most!o_en!given!with!a!local!anestheGc!agent!such!as!bupivacaine!! ADVANTAGES( Rapid!onset!of!pain!relief! Decrease!in!shivering! Less!dense!motor!blockade! SIDE(EFFECTS( Pruritus! Urinary!retenGon! Immediate!or!delayed!respiratory!depression!

COMBINED(SPINALMEPIDURAL(TECHNIQUES(

( May!provide!rapid!and!eecGve!analgesia!for!labor!as!well!as!for! cesarean!delivery! Needle)through)needle( technique( ( An! introducer! needle! is! rst ! placed! in! the! epidural! space,! then! a! small[gauge! spinal! needle! is ! introduced! through! the! epidural! needle! into! the! subarachnoid ! space.!

LOCAL(INFILTRATION(FOR(CESAREAN(DELIVERY( To! augment! an! inadequate! or! patchy ! regional! block! that! was ! given!in!an!emergency! 1st!![!halfway!between!the! costal!margin!and!iliac!crest! in!midaxillary!line!to!block! the!10th,!11th,!and!12th! intercostal!nerves.!! 2nd![!along!the!line!of! proposed!skin!incision.!! 3rd![!at!the!external!inguinal! blocks!the!genitofemoral!and! ilioinguinal!nerves.! !

1! 2!

3!

GENERAL(ANESTHESIA(

( PATIENT(PREPARATION( ( ANTACIDS( ( Administered!shortly!before!inducGon!of!anesthesia! Sodium! citrate! with! citric! acid! (Bacitra)! 30mL( given( 45( minutes!before!surgery! UTERINE(DISPLACEMENT( ( With! lateral! uterine! displacement,! the! duraGon! of! general ! anesthesia! has! less! eect! on! neonatal! condiGon! than! when ! the!woman!remains!supine.!

GENERAL(ANESTHESIA!
Preoxygena4on(
( Because! funcGonal! reserve! capacity! is! reduced, ! pregnant! women! become! hypoxemic! more! rapidly ! during!periods!of!apnea!than!do!nonpregnant!paGents.! 100%! oxygen! via! face! mask! for! 2[3! minutes! prior! to ! anesthesia! inducGon! to! replace! nitrogen! in! the! lungs ! with!oxygen!

INDUCTION(OF(ANESTHESIA!

Thiopental( ( Ease!and!rapid,!with!minimal!risk!of!vomiGng! Poor!analgesic!agents! May!cause!appreciable!newborn!depression!if!given!alone!! ( Ketamine( ( Used!to!render!paGent!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!hallucinaGons!are!commonly!induced!by! this!agent.!

INTUBATION( ( Succinylcholine(( R apid[onset! and! short[acGng! muscle ! relaxant! Sellick(maneuver((Cricoid!pressure!is!used ! to! occlude! the! esophagus! from! inducGon ! unGl!intubaGon!!

Failed(Intuba4on(

( Although!uncommon,!failed!intubaGon!is!a!major!cause!of! anesthesia[related!maternal!mortality.! A!history!of!previous!diculGes!with!intubaGon!as!well!as ! a! careful! assessment! of! anatomical! features! of! the! neck, ! maxillofacial,!pharyngeal,!and!laryngeal!structures!may!help ! predict!a!dicult!intubaGon.! Edema! of! the! airway! may! develop! intrapartum! and ! present!considerable!diculGes.!

Failed(Intuba4on(
Morbid!obesity!is!also!a!major!risk!factor!for!failed!or!dicult ! intubaGon.! An! important! principle! is! to! start! the! operaGve! procedure ! only!a_er!it!has!been!ascertained!that!tracheal!intubaGon!has ! been! successful! and! that! adequate! venGlaGon! can! be ! accomplished.! Following!failed!intubaGon,!the!woman!is!venGlated!by!mask ! and! cricoid! pressure! is! applied! to! reduce! the! chance! of ! aspiraGon.! Surgery! may! proceed! with! mask! venGlaGon! or! the! woman ! may!be!allowed!to!awaken.!!

GAS(ANESTHETICS!

GAS(ANESTHETICS!
Vola4le(Anesthe4cs( ( Most!commonly!used!is!isourane.! Potent! nonexplosive! agent! that! produce! remarkable! uterine! relaxaGon!when!given!in!high,!inhaled!concentraGon! USES:( Internal!podalic!version!of!the!second!twin! Breech!decomposiGon! Replacement!of!acutely!inverted!uterus! Occasionally! associated! with! hepaGGs! and! massive! hepaGc ! necrosis!

GAS(ANESTHETICS!
Anesthesia(Gas(Exposure(and(Pregnancy(Outcome( ( All! anestheGc! agents! that! depress! the! maternal! central!nervous!system!cross!the!placenta!and!depress! the!fetal!central!nervous!system.! InducGon[to[delivery!Gme!should!be!minimized!

GAS(ANESTHETICS!
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! saturaGon! with! spontaneous!respiraGon.! ASPIRATION( ( AspiraGon! pneumoniGs! has! been! the! most! common! cause ! of!anestheGc!deaths!in!obstetrics.!

Fas4ng( ( A! fasGng! period! of! 8! hours! or! more! is! preferable! for! uncomplicated! parturients! undergoing! elecGve! cesarean! delivery.! Pathophysiology( ( The! right! mainstem! bronchus! usually! oers! the! simplest ! pathway! for! aspirated! material! to! reach! the! lung ! parenchyma,! and! therefore! the! right! lower! lobe! is! most ! o_en!involved.! The! woman! who! aspirates! may! develop! evidence! of ! respiratory! distress! immediately! or! as! long! as! several! hours ! a_er!aspiraGon,!depending!in!part!on!the!material!! aspirated!and!the!severity!of!the!process.!

Treatment( ( Respiratory! rate! and! oxygen! saturaGon! as! measured ! by! pulse! oximetry! are! the! most! sensiGve! and! earliest ! indicators!of!injury.! When! acute! respiratory! distress! syndrome! develops, ! mechanical! venGlaGon! with! posiGve! end[expiratory ! pressure!may!prove!lifesaving.! (

Types of Analgesic and Sedation( ( Eects(

Meperidine(50M100mg( with(Promethazine(25mg( IM(every(3(to(4(hours( Does(not(lead(to( prolonga4on(of(labor,( rather(an(increase(in( uterine(ac4vity(

Side(Eects( Depressant(eect(in(the( fetus(follows(peak( analgesic(aect(in(mother(

Butorphanol(1M2mg(

Compares(with(40M60mg( Not(given(con4guously( of(Meperidine( with(Meperidine,( Less(respiratory( antagonizes(the(narco4c( depression( eect(of(Meperidine( Safe,(without(eect(on( ac4ve(phase(of(labor( No(neonatal(depression(

Fentanyl(50M100ug/hr(

Nalbuphine(15M20mg(IM( or(IV(

General Anesthesia! ! Route!of!

Nitrous! Oxide(
AdministraGon( InhalaGon(

Mechanism!of!AcGon(

Advantages(

Disadvantages(

Alter!the!funcGon!of! Low!potency,!therefore! Produces!analgesia! receptors!for! must!be!combined!with! and!altered! neurotransmi^ers,! other!agents;! consciousness;! nonselecGvely,! Rapid!inducGon!and! Risk!of!bone!marrow! controlling!the!overall! recovery;! depression!due!to! state!of!consciousness! Good!analgesic! inhibiGon!of! and!response!to! properGes;! Methionine!synthase! sensory!sGmuli( Does!not!prolong!labor!or! with!prolonged! interfere!with!uterine! administraGon!( contracGons!( Same( Halogenated!anaestheGc! Some!risk!of!epilepsy[ similar!to!halothane;! like!seizures( Less!metabolism!than! halothane,!therefore!less! risk!of!toxicity;! Fast!inducGon!and! recovery!than!halothane! (less!accumulaGon!in!fat)(

Enurane(

InhalaGon(

Route!of! Mechanism!of! AdministraGon( AcGon(

Advantages(

Disadvantages(

Isourane(

InhalaGon(

Same(

Similar!to!Enurane,!but! Unconsciousness;! lacks!epileptogenic! PotenGal!for!aspiraGon!in!an! property;! unprotected!airway;! May!precipitate! Crosses!the!placenta!produce! myocardial!ischaemia!in! narcosis!in!the!fetus;! paGents!with!coronary! Produces!uterine!relaxaGon!in! disease( high!doses(

Halothane(

InhalaGon(

Same(

Widely!used!agent(

PotenGal!for!aspiraGon!in!an! unprotected!airway;! Crosses!the!placenta!produce! narcosis!in!the!fetus;! Produces!uterine!relaxaGon!in! high!doses;!! Risk!of!liver!damage!if!used! repeatedly(

Pudendal!block(

ComplicaGons!and!their! PrecauGons( Management( Provide!analgesia!for! Intravascular!injecGon! May!not!provide!adequate!analgesia! spontaneous!delivery! may!cause!serious!toxicity! for!other!than!outlet!delivery!or!when! Can!be!used!with!epidural! characterized( delivery!requires!extensive! analgesia!given!during! manipulaGon( labor( Provide!good!to!excellent! Fetal!bradycardia,!as!a! pain!relief!during!the!rst! consequence!of! stage!of!labor( transplacental!transfer!of! the!anestheGc!agent( For!forceps!and!vacuum! Hypotension! delivery( Total!spinal!blockage! Spinal!headache! Convulsions! Bladder!dysfuncGon( Relief!of!pain!of!uterine! Hypotension! contracGons!and!delivery,! Urinary!retenGon! vaginal!or!abdominal( Cardiorespiratory!arrest! Maternal!pyrexia! Back!pain( RelaGvely!short!acGng,!may!have!to!be! repeated!during!labor(

IndicaGon(

Paracervical! block( Spinal! (subarachnoid)! block!( Epidural!block(

Disorder!of!coagulaGon!and!defecGve! hemostasis!preclude!the!use!of!spinal! analgesia(

Before!any!injecGon!of!the!local! anestheGc!agent,!a!test!dose!is!given! and!the!women!observed!for!features! of!toxicity!from!intravascular!injecGon! and!signs!of!spinal!blockade!form! subarachnoid!injecGon(