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Always controversial! Birth is a natural process Women should suffer!! Concerns for mothers safety Concerns for baby Concerns for effects on labor
John Snow (1853) on Queen Victorias Anesthetic for the birth of Prince Leopold:
The inhalation lasted fifty-three minutes. The chloroform was given
Good pain relief No autonomic block (no hypotension) No adverse maternal or neonatal effects No motor block No effect on labor and delivery:
No increase in C/S rate No increase in forceps/vacuum delivery
pH
Systemic narcotics Tranquilizers / hypnotics Inhalation analgesia Acupuncture TENS Psychoanalgesic techniques
Lipid solubility
Molecular size
Total dose of drug Concentration gradient
(Ralston, 1987)
Differential maternal and fetal protein binding accounts for differences in total circulating drug concentrations on both sides of placenta, when free drug concentrations are actually equal
Bupivacaine:
0.25-0.3
Mepivacaine:
Lidocaine:
0.7
0.5
Correlates with degree of protein binding, but may not reflect total amount of drug in
(2.4)
(1)
(1)
(6)
From the American College of Obstetricians and Gynecologists, Obstet Gynecol 1976; 48:29)
Easy administration
Inexpensive No needles Avoids complications of regional block Does not require skilled personnel
Morphine:
long half-life, neonatal depression Meperidine: neonatal depression (normeperidine effect) nausea, vomiting Fentanyl: short duration, minimal newborn effects Alfentanil: newborn depression Remifentanil? (what surveillance is needed?)
6 6 4 4 2 2 0 0
Meperidine Fentanyl
4-7 cm
8-10 cm
(Data (Data from from Rayburn Rayburn et et al. al. Obstet Obstet Gynecol Gynecol 1989;14:604) 1989;14:604)
Nalbuphine
Butorphanol
Buprenorphine
(Anesthesiology, 1982)
Transient, global depression of behavior related to presence and quantity of drug in newborn
Most effects gone by 3rd day; all by 10 days Important to differentiate from sinister causes
Advantages:
Easy to administer (no needles or PDPH) Satisfactory analgesia variable Minimal neonatal depression
Disadvantages:
Decreased uterine contractility (except N2O) Rapid induction of anesthesia in pregnancy Risk of unconsciousness and aspiration Difficulties with scavenging in labor rooms
Local infiltration
Pudendal block Paracervical block Paravertebral (lumbar sympathetic block) Epidural - lumbar (caudal) Spinal Combined spinal-epidural (CSE)
Paracervical Block
Lumbar epidural
Apgar scores, acid-base status, unaffected Neurobehavioral effects absent with current agents
Good pain relief No autonomic block (no hypotension) No adverse maternal or neonatal effects No motor block No effect on labor and delivery:
No increase in C/S rate No increase in forceps/vacuum delivery
Local Anesthetic
Opioids
Chloroprocaine:
rapid rapid onset, onset, low low toxicity, toxicity, dense dense block, block, antagonizes antagonizes bupivacaine bupivacaine and and opioids opioids
Bupivacaine:
good good sensory, sensory, minimal minimal motor motor block, block, no no adverse adverse effect effect on on labor labor with with 0.0625% 0.0625%
Ropivacaine:
lower lower toxicity, toxicity, ? ? less less motor motor block, block, less less potent potent
(2 MLAC studies*)
Claims for reduced toxicity and motor block must consider relative potency
Do very dilute agents pose risk of toxicity? Newer agents very expensive
Relative Analgesic and Motor Blocking Potencies of Epidural Bupivacaine and Ropivacaine in Labor
Motor block potency ratio is the same as sensory block potency ratio Ropivacaine is only 0.66 as potent as bupivacaine
Low specificity - maternal heart rate very variable Low sensitivity - response to sympathomimetics Increases motor block - prevents ambulation Potential for UBF with repeated doses Very dilute agents - whole first dose is test dose.
Inadequate analgesics used alone Synergize with local anesthetics Speed onset of analgesia Improve quality of analgesia
OPIOID
PCEA
Good analgesia Patient autonomy Less need for MD interventions Cost effective
Effect of Low-Dose Mobile vs. Traditional Epidural Techniques on mode of delivery: A randomized Trial
(Comet Study UK , Lancet 2001;358:19)
50
% Patients
40 30 20 10 0 "Traditional"
Bupivacaine 0.25%
CSE
Bupiv 2.5 mg + Fent 25 mcg
Low-dose Infusion
Bupivacaine 0.1% + fentanyl
Effect on Instrumental Vaginal Delivery Rate of Continuing Epidural Infusion During the Second Stage of Labor
0.125% 0.125% bupivacaine bupivacaine vs. vs. 0.0625% 0.0625% bupivacaine bupivacaine + +2 2 g/ml g/ml fentanyl fentanyl Infusion Infusion continued continued Infusion Infusion discontinued discontinued
53 53
*
28 28
21 21 15 15
0.125%Bup 0.125%Bup
Median Upper and Lower Level of Decreased 10 g Pinprick Sensation after Intrathecal Sufentanil 10 g
100 75
CSE Epidural
VAPS (0-100)
50 25 0 Baseline 5 10 15 20
Time (minutes)
The Problem
Figure 1. Cardiotocogram (1 cm/min) showing: 1) typical uterine hyperactivity with fetal distress, 2) administration of g administered), 3) resolu tion o f the hyperactivity with normalization of fetal heart intravenous nitroglycerin (arrow, 90 ra te, and 4) rapid rea ppearan ce of regular uterine a ctivity. Anesth An alg 1997; 84 :1117 20
Journal Conte nt Copyright 1991-Pre se nt, ASA, IARS, BJA, CAS. All Rights Re se rv e d. Re pr oduction of said mate r ial, without prior pe rmission fr om the Proprie tor holding the copyright to the mate r ial, is ille gal.
CSE Epidural
20
%
10
*
0 Nielsen Palmer Riley Eberle
Nielsen et al. Anesth Analg 1996; 83:7426 Palmer et al. Anesth Analg 199;88(3):577-81 Riley et al. Anesthesiology 1999; A1054 Eberle et al. Am J Obstet Gynecol 1998; 179:150-155
Fetal Heart Rate after CSE - Selection Bias May Contribute to Higher Incidence of Fetal Bradycardia Riley...Cohen et al. Anesthesiology 1999; A1054
20
* *
CSE Epidural
15
10
Greater Pain Scores and Cervical Dilation Before Analgesia May Contribute to Bias
Riley...Cohen et al. Anesthesiology 1999; A1054
10
*
8 6
Epidural CSE
(n = 196)
*
4
O2 administration
STOP OXYTOCIN!
Fetal scalp stimulation Nitroglycerin: 400 g sublingual X 2 (or more) 100 g IV repeated as needed
Terbutaline 0.25 mg, subcutaneous Treat hypotension Ephedrine - epinephrine level; UBF
2.0 1.6 % Patients 1.2 0.8 0.4 0.0 Dural Puncture Headache EBP
CSE Epidural
(n=2183)
Combine with:
Local anesthetic (bupivacaine 1.25-2.5 mg) Epinephrine? Clonidine? (Neostigmine?)
Use lowest effective dose of opioid, dont repeat Monitor BP, FHR, Respiration, (SpO2 if indicated) Expect potentiation of epidural doses
Treat hypotension and uterine hypertonus Naloxone and resuscitation equipment available Same or greater surveillance as after epidural
Controversial Areas
Conclusions