OBSTETRIC

ANAESTHESIA
GROUP MEMBERS
JAMIEE WILKINSON
RONN JOHNSON
CAROL WILLIAMS
ARIANNE JORDAN
Introduction
 They are many options that may be employed for
the provision of analgesia and anaesthesia in the
obstetric patient.

 The physiologic changes that occur during

pregnancy however, must be considered in this
application as they impact the provision of safe
anaesthesia care for the mother and child.
Maternal Physiology
 Beginning in the first trimester and continuing until
after delivery, pregnancy results in physiologic
changes in many organ systems including:
 Cardiovascular
 Respiratory
 Neuronal
 Gastrointestinal
 Renal
 Haematological
Cardiovascular Changes
 Intravascular blood volume increases by 35%.
 Normal vaginal delivery causes a blood loss of up
to 500 ml.
 Cardiac output increases by 40% at term
 Decreased systolic blood pressure
 The uterus at term receives up to 20% of maternal
cardiac output.
 100% increase in cardiac output during labour
 Supine hypotensive syndrome
Respiratory Changes
 Minute ventilation increases during pregnancy
 The resting arterial partial pressure of
carbondioxide decreases to about 30mmHg.
 Lung volumes change
 Functional residual capacity decreases, reducing
the potential oxygen stores during anaesthesia.

 Pregnant women require placement of a smaller

endotracheal tube
Neuronal Changes
 Pregnancy decreases anaesthetic requirements
causing :
 Reduced minimum alveolar concentration for
volatile anaesthetics
 Increased sensitivity to local anaesthetics
 Reduced doses administered for epidural and spinal
anaesthetics.
Gastrointestinal Changes
 There is an increased risk of regurgitation of acidic
gastric contents.
 Gastric emptying is delayed during labour because of
the pain, especially if opioids are given or the patient
is obese.
 During GA after 18-20 weeks of pregnancy and up to
18 hours after delivery, the airway should be
protected with a cuffed endotracheal tube.
 Recommended histamine receptor antagonist and
non particulate antacid given before GA.
Renal Changes
 Increased renal blood flow
 Increased glomerular filtration rate and creatinine
clearance.
 The renal calyces are dilated from the second
trimester leading to urinary stasis increasing the
risk of urinary tract infection.
Hematological Changes
 Greater increase in plasma volume relative to that
of the red cell volume resulting in a physiologic
anaemia.
 Hypercoagulable state due to increased fibrinogen,
coagulation factors II, VII, VIII, IX, X, XII,
reduced plasminogen activator and increased
platelets.
 Pregnant patient at risk of DVT.
 The Placenta and Anaesthesia
 Anaesthetic compounds cross the placenta via diffusion
The quantity of drug transferred is determined by:
 Molecular weight
 Degree of ionisation
 Lipid solubility
 Protein binding
 Concentration gradient from maternal to foetal circulation

 Neuromuscular blockers are water soluble, ionised and have

higher molecular weights, so they do not cross the placenta
readily.
Labour, Delivery and
Anaesthesia
 During labour, painful contractions increase
minute ventilation by up to 300%
 Blood pressure increaes during cardiac contractions
 Cardiac output increases after delivery
 Contractions also increase catecholamine levels

 Cardiac output rises immediately after birth due to

autotransfusion of 500-750ml of blood from the
sustained contraction on an empty uterus.
 PAIN RELIEF

 Pain relief is a popular request on Labour and Delivery

Wards
 Pain may be relieved by
 Child birth preparation techniques
 Non-pharmacologic methods
 Pharmacologic methods eg. Epidurals
*this is where the anaesthetist comes in*
 Choice depends on
 Circumstances of labour and delivery
 preferences of anesthetist/patient
Pre-Anesthesia Screening - general

 History
 Pre-op diagnosis, planned procedure, PMH
 PSH with anesthetic problems if any
 Medications, allergies,
 Familial anesthetic problems
 Physical Examination
 Height and weight
 Baseline vitals
 Head and neck, CVS, Respiratory exams
 ASA physical status, pregnancy is classified as CLASS I/II
Anesthetic Screening
 Aim: Identify high risk patients
 Including but not limited to patients who:-
 Are morbidly obese
 Have severe facial or neck oedema
 are short relative to their weight
 Have difficulty opening their mouths
 Have and anatomical abnormality of face and mouth
 Have small mandible and/or protuberant teeth
 Have Arthritis of the neck
 Have a large thyroid
Anesthetic Screening
 Have placenta previa/abruption/accreta
 Moderate/severe asthma
 Neurological disorders
 Pre-eclampsia
 Significant medical/obstetric problems
 History of prior difficulty with anesthesia
STAGE
1
DILATION
Systemic Analgesia
 Pain relief delivered to body via IV or IM route.

 Used for natural (vaginal) birth.

 Agents employed are opioids.

 In the spinal mechanism of opioid analgesia , the sites of action

are the receptors in the substantia gelatinosa region of the spinal
cord.

 Opioid Receptor types specific to spinal analgesia are μ2 ,δ and κ1

 Parenteral opioids
Drug Usual Dose Onset of DOA Comments
Action (mins) (mins)

Pethidine 1 – 2 mg/kg IM 15 – 20 IV 30 – 60 Used in early stages of

labour as analgesia. Marked
* nausea and vomiting.
(meperidine
)
Morphine 0.1 – 0.15mg/kg IV 5 – 10 IV 45 – 60 Infrequent use in labour;
0.2 – 0.3mg/kg IM 20- 30 IM 60 – 120 greater neonate respiratory
depression

Fentanyl 1 – 3 mcg/kg IV 2-3 IV 20 - 30 Short acting potent

respiratory depressant. Used
as continuous infusion. Max
dose 600 mcg.
Cumulative effect with large
doses
Side effects of opioids
 S/E include:
 Nausea, vomiting, delayed gastric emptying
 Dysphoria, drowsiness
 Resp. depression
 Readily crosses placental due to high lipid solubility and
low molecular weight
 Decrease fetal HR
 Neonatal respiratory depression
 Prolonged elimination and metabolism in neonates
Regional Anaesthesia
 Anaesthetic agents applied to a specific region of the
body, aimed at affecting the nerves there only

 Patient needs to remain conscious as well as retain

motor function in order to retain the ability to push the
baby out, this is not afforded under general
anaesthesia.

 The airway reflexes are preserved and in a pregnant

patient, with increased risk of aspiration, the risk is
reduced.
Regional vs systemic pain relief

SYSTEMIC REGIONAL
Act on nerves on a system Acts locally on nerves that
level. Produce drowsiness and transmit pain from uterus and
sedation vagina so patient is alert and
able to fully participate in
second stage of labour

Large dose of medication Small dose of medication

required to relieve pain required to relieve pain
Types of regional analgesia used
 Epidural analgesia – Stage 1, 2, 3

 Spinal analgesia – Stage 2

 Combines spinal and epidural analgesia – Stage 2

EPIDURAL ANALGESIA

 The epidural space is the potential space outside the

spinal dural sac which extends from the foramen
magnum to the sacro-coccygeal membrane.

Boundaries:
Ant- posterior longitudinal ligament
Post- ligamentum flavum, vertebral laminae and pedicles
Laterally- interveretebral foramen
EPIDURAL ANALGESIA

 Local anaesthetic is deposited into this space. It acts by

blocking neural transmission by diffusing intrathecally and
anaesthetising spinal nerve roots and blocking spinal nerves
as they emerge.
Effective analgesia during the first stage of labour may be
achieved by blocking T10 – L1 dermatomes with dilute
concentration of local anaesthetic with or without the use
opioids.
 A single dose can be given , or a catheter can be inserted so
that repeated injections or a continuous infusion can be given
Technique
 The patient may be seated, lateral or prone
 The iliac crest is a commonly used landmark as it
roughly corresponds with L4 which is well below the
termination of the spinal cord.
 The Tuohy needle is usually inserted in the midline
between the spinous processes. (16, 17 gauge)
 The ‘loss of resistance’ technique is used.
 A catheter may be placed into the epidural space
through the needle through which the analgesia can be
administered as a bolus, repeated or continuous dose.
TUOHY NEEDLE
 AGENTS
 Can be a local anaesthetic, an opioid or both
Local anaesthetic Opioid
Bupivicaine * Fentanyl *
Levobupivicaine Sufentanil
Mepivicaine Pethidine
Ropivicaine Morphine

 5-10ml of Bupivicaine (0.125% - 0.25%) followed by a

continuous infusion (8-12ml/hr) of 0.625% Bupivicaine.
 The addition of 1 – 2mcg/ml of Fentanyl permits a more
dilute local anaesthetic solution to be administered

* Used at UHWI
Advantages and disadvantages
 Advantages
• Better pain relief
• Smaller risk of respiratory depression in babies after birth

 Disadvantages
• Increased risk of muscular weakness for a period time after
birth
• More use of instruments to assist with birth
• Longer second stage of labour (delivery)
• Increased need of oxytocin to stimulate uterine contractions
• Increased risk of experiencing very low blood pressure
Ensure…..
 Routine hydration (1000cc/hr Ringer’s Lactate to
facilitate drop in blood pressure associated with
epidurals)

 To monitor blood pressure and heart rate, oxygen

saturation and fetal heart rate. Maternal systemic blood
pressure should be monitored every 2- 5 minutes for
the 5 – 20 minutes after initiation of the block then at
regular intervals afterward.
STAGE
2
FETAL EXPULSION
EPIDURAL ANAESTHESIA
 This type of regional anaesthesia can be continued for
use during stage 2 of labour. If indicated, the dose can be
changed to induce anaesthesia for a caesarian section.

 Due to the pain from vaginal distension and perineal

pressure, the block should be extended to include the
S2-S4 segments of the cord.

 These sacral dermatomes may be blocked with 10ml of

0.5% Bupivicaine.
 Prolongation of labour by epidural analgesia
(presumably related to loss of urge to push by
patient) may be minimized by the use of an ultra
diluted concentration of local anaesthetic with or
without combination of an opioid.

 Opioids can cause respiratory depression in the

newborn. There should there be an opioid antagonist
readily available for treatment if needed. Naloxone
is commonly used. The dose is 0.1 mg/kg.
Anaesthesia for C-Section
 Epidural – 2 Chloroprocaine 3%, Lidocaine 2%
with epinephrine 1:200,000, 0.5% Bupivicaine,
Ropivicaine or Levobupivicaine

 Spinal

 Combined spinal-epidural

 General Anaesthesia
SPINAL ANALGESIA

 The anaesthetic is injected directly into the

cerebrospinal fluid within the subarachnoid space

 This method of regional anaesthesia used mainly

for surgical procedures. In this case, a Caesarian
section.
 The desired effect is to block the transmission of afferent nerve
signals from peripheral nociceptors. Sensory signals from the
site are blocked, thereby eliminating pain. The degree of
neuronal blockade depends on the amount and concentration
of local anaesthetic used and the properties of the axon. Thin
unmylenated C-fibres associated with pain are blocked first,
while thick, heavily mylenated A-alpha motor neurons are
blocked last. The desired result is total numbness of the area. A
pressure sensation is permissible and often occurs due to
incomplete blockade of the thicker A-beta mechanoreceptors.
This allows surgical procedures to be performed with no
painful sensation to the person undergoing the procedure.
Technique
 IV access
 Monitors
 Full facilities for resuscitation if needed
 Aseptic Technique: full gown,cap, mask and
Betadine
 Consent
 Skilled personnel
Technique
 1. Position the patient on the side with the spine
flexed (lateral decubitus position)
 2. Identify the L3-4 interspace on an imaginary line
joining both iliac crests
 3. Raise a skin wheal at the centre of the interspace
 4. Advance the spinal needle with its stylet in place
in a direction perpendicular to the skin but pointed
slightly cephalad.
 Needle size – 22, 24 or 25 gauge.
Note: A Clear flow of CSF when the stylet is
removed confirms that the tip of the needle is in
the subarachnoid space.

Local anaesthetic is ONLY injected when there is

free flow of CLEAR CSF.

 The needle is then withdrawn

 Patient is turned to supine position
Spinal Needles
 Spinal needles are named and distinguished based on
the design of their tip:
* Quincke : “medium cutting beveled and sharp”
*Sprotte: “pencil point”
*Whitacre : “pencil point”
*Greene : “non cutting bevel”

All spinal needles come with a tight fitting stylet to

prevent the needle from becoming plugged with skin or
fat.
Agents

 Hyperbaric (heavy) solutions: such as

* 0.5% tetracaine in 5% dextrose
* 0.5% bupivacaine in 8.25% dextrose
* 5% lidocaine in 7.5% dextrose
 EPIDURAL vs SPINAL
EPIDURAL SPINAL

Larger injected dose – space involved is Smaller injected dose needed

larger
Indwelling catheter may be placed to One shot dose/Single subarachnoid
allowed for repeat or continuous doses to injection
be given thus Ability to prolong or extend
block via indwelling catheter and it can
also be used for post operative analgesia

Onset of analgesia – 15 – 30 mins Onset of analgesia – 5 mins (more rapid

onset)
Does not cause a significant Has a significant neuromuscular block
neuromuscular block
 EPIDURAL SPINAL

An epidural may be given at cervical, Must be injected below L2 to avoid

thoracic or a lumbar site piercing the spinal cord
Requires more time to perform Requires less time to perform(faster)

Weaker sensory and motor block. Better sensory and motor block

greater risk of postdural puncture Less pain during surgery

headache
Combined Spinal-Epidural Anaesthesia

 Combines spinal and epidural analgesia.

 Ideal use during labour because it combines the

flexibility and longer duration offered by an
epidural catheter and the rapid onset and profound
block of spinal anaesthesia.
Technique
 After identification of the epidural space, a long
pencil point spinal needle is advanced into the
subarachnoid space through the epidural needle.

 After intrathecal injection(spinal injection), an

epidural infusion of Bupivacaine 0.03% to 0.625%
with added opoids is started.
 After the peak spinal block height has been reached, the
injection of local anaesthetic into the epidural space causes
the block height to increase even further
 Side effects of intrathecal opoids:
Pruritis
Nausea and Vomitting
Urinary Retention
Fectal bradycardia may occur

 Risk of this technique is that the meningeal hole made by

the spinal needle after dural puncture, may allow high
concentrations of subsequently administered epidural drugs
to reach the subarachnoid space.
Contraindications to epidural and spinal analgesia

 Acute Hypovolaemia – bleeding, dehydration

 A low, fixed cardiac output - decreased perfusion to organs
 Local skin sepsis – risk of infection
 Coagulopathy or thrombocytopenia– risk of epidural
haematoma
 Raised intracranial pressure – risk of precipitating coning
 Known allergy to amide local anaesthetic
 A patient who is totally unco-operative or refuses
 Abnormal spinal anatomy – Scoliosis, spina bifida
 Cord prolapse
Complications
The most common immediate complication seen following
SPINAL ANAESTHESIA is Hypotension without increase in
heart rate.
Cause of the hypotension is: Loss of the sympathetic tone by
blockage of the spinal nerves.

Can be severe in parturients ,hence maternal systemic blood

pressure is typically monitored every 2-5 minutes for about 15-
20 minutes after the initiation of the block and at regular
intervals thereafter.

Prevention: Give 1 – 1.5L Bolus of Lactated Ringer’s Solution or

Normal Saline before onset of anaesthesia.
Ephedrine in increments of 5mg can be given IV if necessary
PostDural Puncture
Headache
 Brought on by assuming erect position
 Relieved by lying supine
 Usually fronto-occipital
 Caused by: Persistent Leakage/Loss of CSF from the meningeal
needle hole in the dura, causing intracranial hypotension.
 Incidence: Highest in women
 Risk of this decreases with the size of spinal needle used, hence
small gauged needles have lower risk(spinal needles).
 Risk decreases with non cutting tips: Whitacre or Sprotte(pencil
point) lower risk vs Quincke(diamond shape cutting needle) higher
risk
 Risk is greatest with large holes- when a meningeal hole is made
accidentally with a large epidural needle during epidural
anaesthesia.
Conservative Tx:
Bed rest: Pt must be resting supine
Give Analesgics
Hydrate pt with fluid intake
Caffeine
Steroids
Usually resolve spontaneously in a few days with
conservative tx.
 If the headache is persistent, perform the
Autogolous Blood Patch:

 Inject 10-15ml of autologous venous blood into the

epidural space at the level of the original lumbar
puncture under strict aseptic conditions.
 This seals the dural leak
 Curative in over 90% of patients
Other complications of central neural blockade

 Nausea and vomiting

 Transient hearing loss: lasts 2-3 days, common

after spinal anaesthesia

 Total Spinal Anaesthesia

 Spinal Hematoma (rare)

Pay attention….
 During epidural or spinal procedures, the guidelines to
monitoring should be followed. Even though the
patient is conscious, particular attention must be paid,
especially to the CARDIOVASCULAR system.
Maintenance of verbal contact with the patient is
useful as it gives an indication of cerebral perfusion.

 Complaints to look out for :

 Nausea and faintness – early signs of inadequate cardiac output.
Subsequent vomiting may occur
 Difficulty breathing or numbness in fingers – extensive spread of
anaesthesia
General Anesthesia

 Done in patients where regional anesthesia is

absolutely contraindicated or where it is requested
given there are no contraindications to GA
 Uncorrected maternal hypovolemia eg in hemorrhage
 Documented coagulopathy (coagulopathy MUST be
ruled out inpatients with HELLP, abruption or IUFD
and no regional if PT is greater than 1.5)
 Sepsis (chorio-amnionitis is not included but must
receive antibiotics)
 Skin/soft tissue infection at site of needle placement
 Patient refusal/inability to co-operate
Technique
 Pre-oxygenation and a rapid sequence induction are
recommended to protect the woman from aspiration of
gastric contents.
 Muscle relaxation may be achieved with a short-acting
non-depolarising agent.
 Suxamethonium is the relaxant of choice as it can
rapidly produce good intubating conditions and will
have a rapid offset if there is a failed intubation.
 Anaesthetic requirements are decreased during
pregnancy.
 Induction Agents
Drug Usual Dose (mg/kg) Onset of DOA Comments
Action (s) (mins)

Thiopental* 2–6 20– 30 9 – 10 This is the induction agent of

choice, in a dose of 4 mg/kg
to prevent awareness, but
still allow wakening if there
is a failed intubation.
Propofol 1.5 – 2.5 30 – 45 4–7 This is the alternative agent
but may induce more
hypotension.

Ketamine 1–2 50 - 70 10 - 12 This drug can be used in the

management of hypovolemic
women requiring caesarean
section.
Maintenance Agents
Drug MAC in oxygen/air Solubility Comments

Isoflurane* 1.3% Medium High doses of inhalation agents

can cause increased uterine
bleeding.

Sevoflurane 2.2% Low; Rapid changes Popular for inhalation

of depth
induction. Expensive

Desflurane 6.0% Low; Rapid

changes of depth
General Anaesthesia
Advantages:
 It can be given quickly

 Blood pressure and breathing can be easily controlled

 In some situations general anesthesia is preferred to

regional, For example in patients with bleeding and

clotting abnormalities
 Patients with neurological problems

 Patients with infections that might be spread to the

spinal area if regional anesthesia is done

General Anaesthesia
Disadvantages:
 Patient is unconscious and is therefore unable to participate in

the process of birth or interact with the baby once it is

delivered.
 Difficulty placing an airway. E.g endo-tracheal tube.

 Risk of pulmonary aspiration during placement of an airway.

 Risk of fetal depression caused by anaesthetics crossing the

placental barrier.
 Risk of awareness under anaesthesia

 Volatile anaesthetic agents are capable of uterine relaxation

and can predispose to uterine atony and haemorrhage.

General Anaesthesia

 Major concern in the risk of aspiration

 Gastric acid production increases with stress (labour)
 Peristalsis slows with pain/stress/parenteral narcotics
 Result: overall increase in gastric volume during
labour
 Patient will benefit from reduction in gastric volume
and increase in the pH of the contents.

 Thus patient has to follow the regular pre-op

specifications – i.e. No solid food 6 hrs pre-op, clear
fluids taken up to 2hrs pre op etc

 In addition – Metoclopramide – 10mg orally pre op –

increases both gastric emptying and lower oesophageal
sphincter tone. Can be given in conjunction with
ranitidine which is a proton pump inhibitor.
Anti-emetics
Preparation for anaesthesia should include antacid
prophylaxis. Which includes:

Ranitidine - 50 mg intravenously or 150 mg oral 60

minutes before the procedure
Sodium citrate – 30ml given orally to chemically
neutralize residual acid 15 minutes before
anaesthesia
STAGE
3&4
DELIVERY OF THE
PLACENTA
AND PERIOD DIRECTLY
AFTER BIRTH
Post-operative
 After delivery of the baby the anaesthetist can give
the mother an intravenous opioid (pethidine 50 to
100 mg or morphine 5 to 10 mg).

 5 international units (IU) of oxytocin is given

intravenously immediately after the delivery.
One side-effect of oxytocin is relaxation of vascular
smooth muscle that will cause a fall in diastolic and
systolic blood pressure, and a reflex tachycardia.
Hypovolaemic patients may have a serious fall in
blood pressure.
Resources
 http://pediatrics.aappublications.org/content/86/3/4
84.abstract
 Handbook of Clinical Anaesthesia 6th Edition –
Paul G barash et al.
 Essentials of Anaesthesiology 3rd edition – David
C.Chung / Arthur M. Lam
 Lecture notes in Clinical Anaesthesia 2nd edition –
Carl L. Gwinnitt