Obstetric Analgesia and Anesthesia

Gilbert J. Grant

The first modern recorded use of pain relief for childbirth was in 1847, when Dr. James oun! "impson administered ether to facilitate #a!inal deli#er$ for a woman with a deformed pel#is. "ince that time, obstetric anesthesia practice has e#ol#ed from the use of s$stemic routes for anal!esic administration %inhalation, intra#enous, intramuscular& to re!ional administration of anal!esics b$ the epidural and spinal routes. 'urrentl$, in the ("), more than *+, of parturients recei#e re!ional anal!esia to mana!e their pain of childbirth. )n ad#anta!e of the re!ional approach is that relati#el$ low doses of anal!esics reliabl$ pro#ide pain relief. Thus, the fetus is spared e-posure to the relati#el$ lar!e doses of medication re.uired when the s$stemic approach is used. )lthou!h the s$stemic route remains an option, it is currentl$ used for a minorit$ of parturients. This re#iew describes current practices in obstetric anesthesia. Labor and Vaginal Delivery Consequences of unrelieved pain The pain of childbirth, which is li/el$ to be the most se#ere pain that a woman e-periences 011, results in untoward ph$siolo!ic effects 021. The h$per#entilation that accompanies labor pain causes profound h$pocarbia, which ma$ suppress the #entilator dri#e between contractions and produce maternal h$po-emia and loss of consciousness 031. The accompan$in! respirator$ al/alosis interferes with fetal o-$!enation b$ shiftin! the o-$hemo!lobin dissociation cur#e in fa#or of the mother and b$ producin! uteroplacental #asoconstriction 041. The neurohormonal responses to stress and pain also conspire to ad#ersel$ affect placental perfusion and fetal o-$!enation. These chan!es are mediated b$ increases in circulatin! catecholamines, which decrease uterine blood flow 041. 5pidural anal!esia lowers circulatin! maternal epinephrine, and effecti#el$ inhibits the respirator$ 0*1 and neurohormonal 071 responses to pain, with a resultant increase in o-$!en tension in the parturient and fetus081. There is also e#idence that unrelie#ed pain durin! childbirth ma$ contribute to the de#elopment of postpartum ps$cholo!ic problems includin! postpartum depression 061 and post 7 traumatic stress disorder %8T"D& 01+1.

Multimodal Regional Analgesia 'urrent methods for pro#idin! pain relief for labor and #a!inal deli#er$ are considerabl$ different from techni.ues that were used as recentl$ as 14 $ears a!o. 9e!ional anal!esia for childbirth has been transformed from a one:dru! approach usin! a local anesthetic, to an approach in which different classes of anal!esics are administered concurrentl$; most commonl$, a local anesthetic and an opioid. )lthou!h local anesthetics produce profound anal!esia, the$ indiscriminatel$ bloc/ conduction in all ner#es with which the$ come in contact, and therefore also produce unwanted effects< h$potension and motor bloc/. =$potension ma$ decrease fetal o-$!en deli#er$ b$ reducin! placental perfusions. >otor bloc/ ma$ cause profound lower e-tremit$ wea/ness, which can be #er$ distressin! for the parturient. >oreo#er, profound motor and sensor$ bloc/ ma$ interfere with effecti#e pushin! durin! the second sta!e, particularl$ if the parturient is unable to percei#e rectal or #a!inal pressure, as the presence of this pressure facilitates e-pulsi#e efforts. The traditional approach to re!ional anal!esia, in which a local anesthetic was used as the sole a!ent, chan!ed when clinicians reco!ni?ed the anal!esic efficac$ of opioids administered into the neura-is. (nli/e local anesthetics, which act b$ bloc/in! ner#e conduction, opioids in@ected into the neura-is inhibit pain b$ bindin! to specific spinal opioid receptors. Apioids and local anesthetics act s$ner!isticall$, so relati#el$ low doses of each a!ent are re.uired. This s$ner!ism is the rationale for the concurrent use of a combination of different t$pes of anal!esics, and is /nown as multimodal anal!esia 0111. "ome clinicians combine other classes of anal!esics such as those that stimulate adrener!ic %e.!, epinephrine, clonidine& and choliner!ic %e.! neosti!mine& receptors to further potentiate anal!esia. ) distinct ad#anta!e of multimodal anal!esia is that it produces fewers side effects than t$picall$ occur when a local anasthetic is used alone. The difference causes of anal!esics act throu!h different mechanism, and the$ also ha#e distinct side effect profiles. Burthermore, the li/elihood of side effect is reduced because with the multimodal approach a relati#el$ low dose of each component is used. The profound motor bloc/ that was a fre.uent accompaniment of hi!h concentrations ofnlocal anesthetic does not occur with the low concentrations of local anasthetics that are part of the multimodal approach. =$potension, which commonl$ occured with epidural

administration of hi!h concentration of local anasthetic, is also less li/el$ to occur when low concentrations are administered. 8ruto$us and nausea are the most common untoward effects that occur with neura-ial multimodal anal!esics re!imens, and are caused b$ the opioid component. These side : effects ma$ be dose:related, and are more li/el$ to occur with the relati#el$ water:soluble opioid morphine, and less li/el$ to occur with the relati#el$ lipopphilic opioid such as fentan$l and sufentanil. Apioid side effect ma$ be treated b$ intra#enous administration of specific opioid receptor anta!onist such as nalo-one,naltre-one, nalmefene, or nalbuphine. Bortunatel$ low doses of opioid anta!onist selecti#el$ re#erse the unwanted effects without appreciabl$ affectin! the anal!esia. )nother side effects that ma$ occur after intratechal in@ection of opioid alone is fetal brad$cardia or late decelerations of the fetal heart rate, as the result of uterine h$peracti#it$. This effect is twice as li/el$ To occur after intratechal administration of opioid alone than after epidural administration of local anasthetic and opioid %24, #s 11,& 0121. The fetal brad$cardia ma$ be re#ersed b$ administration of tocol$tic, such as terbutaline or nitro!l$cerine. Bor patients, the impro#ed lower e-tremit$ mobilit$ is perhaps the most noticable effects of multimodal anal!esia. )lthou!h commonl$ described as a Cwal/in! epiduralC, this term is a poor descriptor, as few parturients wal/ much durin! labor after their pain is relie#ed. Burthermore, the lac/ of motor bloc/ is not a result of the epidural approach per se, but ma$ also be achie#ed with a spinal approach, or a combined spinal and epidural %combined spinal: epidural, '"5& approach. The primar$ determinant of motor bloc/ intensit$ is the concentration of local anasthetic, not its site of administration.

Epidural spinal and combined spinal ! Epidural analgesia "afe and effecti#e multimodal re!ional anal!esia ma$ be achie#ed b$ usin! the epidural or spinal routes, or a combination of both. )n ad#anta!e of the epidural approach is that a catheter ma$ be inserted into the epidural space to facilitate continuous andDor intermitten anal!esic dosin! to prolon! the duration of pain relief. Eith spinal techni.ues, the durationof anal!esia is limited into the duration of action of a sin!le dose, as catheteri?ation of the intrathecal space is rarel$ performed. The onset of anal!esia is more rapid with the spinal approach %3:4 minutes& than it is

with the epidural approach %appro-imatel$ 1+ minutes&. The '"5 approach offers the ad#anta!es of both spinal and epidural techni.ues; rapid onset of anal!esia and prolon!ed duration if needed. The t$pe of re!ional anal!esia chosen for a particular patient depends on man$ factors. Ane of the most important determinants is the anticipated duration of labor. Fn earl$ labor, when deli#er$ is not e-pected for man$ hours, catheteri?ation of the epidural space is indicated %epidural or '"5 techni.ues& to establish a conduit for administerin! multiple doses of anal!esics. Bor an epidural techni.ue, the anal!esic medication is t$picall$ administered usin! a continuous infusion pump, perhaps with patient: controlled epidural anal!esia %8'5); see below& for a 's5 techni.ue, a dose of anal!esics is administered intrathecal/$ and then a catheter is inserted into the epidural space. The epidural anal!esics ma$ be administered either immediatel$ after the intrathecal in@ection,mor when the pain relief from the initial intrathecal dose be!ins to wane. 5pidural catheteri?ation is a sensible approach at an$ time durin! labor for parturients who ha#e a hi!h li/elihood of an instrumental or operato#e deli#er$, as it permits administrationof additional anesthetics, should the$ be needed.if deli#er$ is imminent, a sin!le:shot spinal is a reasonable choice, because anal!esia onset is rapid. =owe#er, these patients ma$ benefit more from a '"5 techni.ue, as it re.uis little additional time compared to an epidural tchni.ue, and an indwellin! epidural catheterma$ be .uite helpful. The epidural catheter ma$ be used to administer additional anal!esics if deli#er$ does not occur as .uic/l$ as anticipated, if the intrathecal medication does not produce ade.uate anal!esia, or if an instrumental or operati#e deli#er$ is re.uired.

"atient!conolled epidural analgesia 8ro!rammable, microprocessor:controlled infusion pumps facilitate pcise administration of anal!esics into the epidural space. 'ontinuous infusn of anal!esics is ad#ante!eous, as it a#oids the pea/s and #alle$s of pain and relief that occur with intermitten bolus dosin!. 8'5) is a

further refinement of this tchnolo!$. Ari!inall$ introduced for intra#enous use, 8'5) enables the parturient to Cfine:tuneC her pain relief. 8'5) ma$ be administered usin! intermitten boluses e-cluse#el$, or intermitt en boluses superimposed on a bac/!roundinfusion, which appears to be a superior strate!$0131. 8'5) has man$ ad#anta!es o#er non 8'5) techni.ues includin! better anal!esia and decreased anesthetic re.uirement, as well as impro#ed patient satisfaction 0141, because the patient feels empowered b$ ha#in! some control o#er her pain relief. Fdeall$, 8'5) is used to pro#ide anal!esia for the duration of labor and deli#er$. Bor some patients, the low dose deli#ered from the infusion pump ma$ not be ade.uate for the late first sta!e and second sta!e of labor, when a somatic pain component is superimposed on the #isceral pain input.

Analgeti# dan Anastesi Obstetri

Gilbert J. Grant

8en!!unaan pen!hilan! rasa sa/it untu/ persalinan secara modern tercatat pertama /ali pada tahun 1847, saat dr. James oun! "impson memasu//an ether untu/ memfasilitasi persalinan per #a!inam pada wanita den!an deformitas pel#is. "e@a/ saat itu, pen!!unaan anastesi obstetric telah ber/emban! dari pen!!unaan @alur sistemi/ untu/ memasu//an anal!eti/ %inhalasi, intra#ena, intramuscular& /e anal!eti/ re!ional melalui @alur epidural dan spinal. "aat ini, di )", lebih dari *+, pasien parturient menerima anal!eti/ re!ional untu/ mana@emen sa/it saat persalinan. "uatu /euntun!an dari pende/atan re!ional adalah dosis rendah anal!eti/ dapat di!una/an untu/ pen!hilan! rasa sa/it. Jadi fetus tida/ be!itu tere/spos den!an dosis pen!obatan $an! relati#e besar seperti $an! ditemui pada @alur sistemi/. Ealaupun @alur sistemi/ tetap men@adi pilihan, biasan$a di!una/an han$a pada sedi/it pasien, 9e#iew beri/ut ini men!!ambar/an pen!!unaan 7 pen!!unaan anastesi obstetri/. "roses persalinan dan "ersalinan per vaginam $onse#uensi dari nyeri menetap 9asa sa/it pada saat persalinan, $an! mun!/in merupa/an n$eri palin! berat $an! dialami oleh perempuan, adalah efe/ fisiolo!is. =iper#entilasi $an! men!i/uti n$eri saat persalinan

men!hasil/an hipo/arbia, $an! dapat mene/an #entilasi antara /ontra/si dan men$ebab/an hipo/semia maternal dan /ehilan!an /esadaran. )l/alosis respiratori pen$erta berpen!aruh paDa o/si!enasi fetus den!an men!!eser /ur#a disosiasi o/sihemo!lobin untu/ ibu dan men!hasil/an #aso/ontri/si uteroplasenta. 9espon neurohumoral untu/ stress dan n$eri @u!a ber!abun! dan mempen!aruhi perfusi plasenta dan o/si!enasi fetus. 8erubahan : perubahan ini dimediasi oleh penin!/atan sir/ulasi /ate/olamin, $an! menurun/an aliran darah uterin. )nal!eti/ epidural menurun/an sir/ulasi epinefrin maternal dan secara efe/tif men!hambat respirasi dan respon neurohumoral terhadapmn$eri, den!an total penin!/atan di te/anan o/si!en pada ibu parturien dan fetus. Gu/ti lain @u!a menun@u///an bahwa n$eri /enetapmselama proses /elahiran dapat ber/ontribusi /e per/emban!an masalah psi/olo!i post partum termasu/ depresi post partum dan post traumatic stress disorder %8T"D&. )nal!eti/ re!ional multimodal >etoda terbaru untu/ pen!hilan! rasa sa/it saat melahir/an dan partus per#a!inam sudah berbeda den!an te/ni/ $an! di!una/an 14 tahun $an! lalu. )nal!eti/ re!ional untu/ persalinan telah berubah daru pen!!unaan 1 @enis obat den!an anastrsi lo/al /e pende/atan den!an berba!ai tipe anal!eti/ $an! berbeda $an! dimasu//an secara bersamaan, $an! palin! umum adalah pen!!unaan anestesi lo/al dan !olon!an opioid. Ealaupun anestesi lo/al mempun$ai efe/ anal!eti/ $an! n$ata, namun /er@an$a adalah men!hambat /ondu/si pada semua ner#us $an! ber/onta/ den!ann$a tanpa ada perbedaan sehin!!a @u!a menimbul/an efe/ sampin! seperti hipotensi dan blo/ motori/. =ipotensi dapat menuru/an pen!hantaran o/si!en fetus den!an men!uran!i perfusi plasenta. Glo/ motori/ dapat men$ebaG/an /elemahan e/stremitas bawah $an! n$ata dan dapat men@adi pen$ulit untu/ ibu $an! a/an melahir/an. "elan@utn$a blo/ pada motori/ dan sensori/ @u!a terlibat pada pendoron!an $an! efe/tif saat /ala FF, /hususn$a @i/a ibu inpartu tida/ bisa merasa/an te/anan rectal atau #a!inal. )dan$a te/anan : te/anan tersebut dapat men$ebab/an usaha : usaha e/spulsif. 8ende/atan lama terhadap anal!eti/ re!ional dimana anastesi lo/al di!una/an seba!ai a!en tun!!al, berubah saat do/ter : do/ter menemulan /e!unaan anal!eti/ dari opioid $an! dimasu//an /e neura-is. Gerbeda dari anastesi lo/al $an! be/er@a memblo/ /ondu/si ner#us, opioid disunti//an /e neura-is, men!hambat n$eri den!an beri/atan /e resptor spesifi/ spinal opioid. Apioid dan anastesi lo/al be/er@a secara siner!is sehin!!a dibutuh/an dalam dosis

rendah dari masin! : masin! a!en. Hesiner!isan ini rasional untu/ pen!!unaan bersamaan dari /ombinasi beberapa tipe anal!eti/ $an! berbeda dan di/enal den!an multimodal anal!eti/. Geberapa do/ter men!/ombinasi/an @enis : @enis anal!eti/ lain seperti $an! dapat menstimulasi adrener!i/ dan reseptor /oliner!i/ untu/ anal!eti/ potensial selan@utn$a.