Obstetric Anesthesia

Dr. Marites M. Butaran | June 19, 2021

Trans by: Dela Cruz, Fernando, Nava, Sibalon, Tamacay

OUTLINE • Pain Relief Principles

→ During 1st stage, the pain of labor is transmitted by the
I. Obstetrics Anesthesia VI. Regional Technique Other
sensory innervation of the uterus that passes mainly through
II. Maternal Factors That May Than Epidural for Control of
11th and 12th thoracic segments with some involvement of
Prompt Anesthetic Labor Pain and Vaginal
T10 and L1 segments
Consultation Delivery
III. Epidural Block for Labor A. Paracervical Block → Pain from the uterus is communicated via:
 Uterine plexus –- pelvic (inferior hypogastric) ganglia and
and Vaginal Delivery B. Saddle (Subarachnoid)
plexus –- lumbar and lower thoracic sympathetic chain
IV. Analgesia and Sedation Block
and the white rami communicans
During Labor C. Pudendal Block
A. Parenteral Agents VII. Neuraxial Analgesia  Pain stimuli enter the spinal cord through posterior roots
B. Inhaled Agents A. Spinal (Subarachnoid) of T11 and T12
C. Regional Analgesia Block IV.ANALGESIA AND SEDATION DURING LABOR
V. Anesthetic Agents B. Epidural Analgesia Table 2. Anesthetic Agents and their Dosages [Doc’s ppt]
Monitoring VIII. Local Infiltration for Neonatal
A. Anesthetic Agents – Cesarean Section Agent Usual Dose Frequency Onset
Half-Life
Toxicity IX. General Anesthesia for
25-50 mg (IV) Q 1-2 hr 5 min (IV)
B. Management of Local Cesarean Section 18-20 hr
Meperidine 50-100 mg Q 2-4 hr 30-45
Anesthetic Systemic X. Postpartum Analgesia 60 hr
(IM) min (IM)
Toxicity XI. Footnotes by Doc
50-100 ug (IV)
XII. References Fentanyl Q 1 hr 1 min 5 hr

I. OBSTETRIC ANESTHESIA 5 min (IV)

2-5 mg (IV)
Morphine Q 4 hr 30-40 7 hr
• When to give anesthesia? 10 mg (IM)
min (IM)
→ Control of pain is indicated and initiated when the parturient
complains of pain and asks for relief regardless of cervical A. PARENTERAL AGENTS
dilatation. 1. Promethazine
→ The decision to start epidural analgesia should be made → 25 mg (IM), tranquilizer and anti-emetic
individually with each patient. 2. Meperidine
→ Most common opioid used WW for pain relief during labor,
II. MATERNAL FACTORS THAT MAY PROMPT cross the placenta, depressant effect.
ANESTHETIC CONSULTATION 3. Butorphanol
1. Body Mass Index >30kg/m2 → Synthetic and opioid receptor agonist-antagonist analgesic,
2. Short or thick neck or skeletal neck abnormality given in 1- to 2-mg IV doses.
→ If the patient has a short neck, it may be difficult to do → Its major side effects are somnolence, dizziness, and
intubation – doc dysphoria.
3. Obstructive lesion: edema, anatomical abnormalities, trauma → transient sinusoidal fetal heart rate patterns
4. Decreased range of motion in opening the mouth or small 4. Nalbupine
mandible. → Mixed opioid agonist-antagonist analgesic
→ Kasi mahirap maganesthesia kung hindi maopen, lalo na → Can be given IM, IV, SQ
kung general anesthesia - doc → Doses is 10-20 mg, every 4-6 hours irrespective of the route
5. Thyromegaly or other neck tumor of administration.
6. Severe preeclampsia syndrome 5. Fentanyl
→ Kapag mataas yong bp, it’s difficult na tusukin yong likod kase → Short-acting and potent synthetic opioid
baka magkaroon ng herniation - doc → May be given in doses of 50-100 ug IV every hour.
7. Bleeding disorders → Main disadvantage: short duration of action
→ When you puncture the spinal cord area tapos may bleeding 6. Remifentanil
disorder, ang tendency pwedeng magkaroon ng bleeding - → Synthetic opioid with an extremely rapid onset of action
doc → Causes apnea.
8. Obstetrical complications with a high risk of operative delivery • Efficacy and Safety of Parenteral Agents
9. Maternal medical complications such as cardiopulmonary → Opioids may cause newborn respiratory depression
disease
→ Naloxone is a narcotic antagonist capable of reversing this
10. Previous anesthetic complications
respiratory depression
III. EPIDURAL BLOCK FOR LABOR AND VAGINAL → It acts by displacing the narcotic from specific receptors in the
DELIVERY CNS.
Table 1. Stages of Labor and Anesthetic Concentrations [Doc’s ppt] B. INHALED AGENTS
Pain • NITROUS OXIDE
Stage of Concentration of → Inhaled nitrous oxide has a rapid onset and offset that
Pathways of
Labor Local Anesthetic provides analgesia during episodic contractions
Parturition
</= 0.25% Bupivacaine → It can be self-administered as a mixture of 50% nitrous oxide
First Explain and 50% oxygen premixed in a single cylinder
T10-L1 </= 0.20%
Stage Support
Ropivacaine
Second S2-S4 <0.20% Ropivacaine BOOK:
Coach • In many cases, nitrous oxide simply serves to delay more
Stage T10-L1 <0.25% Bupivacaine
definitive neuraxial analgesia.

Trans # 22 Obstetric Anesthesia 1 of 5

 • For maximal efficacy, nitrous oxide is inhaled 30 seconds
prior to the start of a contraction, although this prevents
adequate rest for the mother.
C. REGIONAL ANALGESIA
• Nerve blocks provide relief during labor and/or delivery
• These include pudendal, paracervical, and neuraxial blocks such
as spinal, epidural, and combined spinal epidural techniques
V. ANESTHETIC AGENTS MONITORING
• Administration must be followed by appropriate monitoring or
adverse reaction.
• Equipment and personnel to manage these reactions must be
immediately available.
• Serious toxicity follows inadvertent intravenous injection.
Systemic toxicity from local anesthetics typically manifests in the
central nervous and cardiovascular systems.
• Local anesthetic agents are manufactured in more than one
concentration and ampule size, which raises the potential for
dosing errors.
Table 3. Local Anesthetic Agents Commonly Used in Obstetrics
[Doc’s ppt]
A. ANESTHETIC AGENTS – TOXICITY
1. Central nervous system toxicity
→ Early symptoms are those of stimulation.
→ As serum level rise, depression follows.
→ Symptoms:
 light-headedness, dizziness, tinnitus, metallic taste, and
numbness of the tongue and mouth.
→ Patients may show bizarre behavior, slurred speech, muscle
fasciculation and excitation, and ultimately, generalized
convulsions, followed by loss of consciousness.
2. Cardiovascular toxicity
→ Similar to neurotoxicity, cardiovascular toxicity is
characterized first by stimulation and then by depression.
→ Hypertension and tachycardia are soon followed by
hypotension, cardiac arrhythmia, and impaired uteroplacental
perfusion
BOOK:
• No symptoms may develop because signs are usually
induced by higher serum drug levels.
• The notable exception is bupivacaine, which is associated
with neurotoxicity and cardiotoxicity at virtually idenrical
levels.
• Because of its toxicity risk, use of a 0.75-percent solution
of bupivacaine for epidural injection has been proscribed
by the FDA.
B. MANAGEMENT OF LOCAL ANESTHETIC
SYSTEMIC TOXICITY
• Intralipid solution- 20% lipid emulsion solution.
• Administered as rapid intravenous bolus followed by an infusion
on the first sign LAST.
• Control seizures, secure airway, prevent aspiration and
hypoxemia.
• Benzodiazepine (midazolam or lorazepam)
→ Is used if lipid emulsions are not available.
• Magnesium sulfate also controls convulsions.
Trans # 22 Obstetric Anesthesia
• It is the best for the fetus and mother to delay delivery until the
mother is stabilized.
• With cardiac arrest, emergency caesarean delivery is considered
if maternal vital signs have not been restored within 5 minutes.
• As with convulsions, however, the fetus is likely to recover more
quickly in utero once maternal cardiac output is re-established.
VI. REGIONAL TECHNIQUE OTHER THAN EPIDURAL FOR
CONTROL OF LABOR PAIN AND VAGINAL DELIVERY
• Paracervical block (for 1st stage of labor)
• Pudendal block (for 2nd stage of labor)
• Saddle block (for 2nd stage of labor)
• Local infiltration
→ But its analgesic effect is limited to episiotomy and
episiorrhaphy.
A. PARACERVIVAL BLOCK
• For the 1st stage of labor
• Simple and effective procedure.
• Blocks the uterine pain pathway at the pelvic (inferior hypogastric)
ganglia and plexus.
• Seldom used because of possible fetal bradycardia due to
placental transfer of anesthetic agent.
• May not be a sign of fetal asphyxia because it is transient and
newborn is usually vigorous at birth.
• Parturient is placed in lithotomy position.
• 5-10cc of 1% Lidocaine or 0.25% Bupivacaine is injected in the
lateral fornices of the vagina at 3 o'clock or 9 o'clock or 4 & 8
o'clock position of the cervix and carefully aspirating for blood
with the needle tip resting on the uterosacral ligament.
• Gauge 21-23 spinal needle if used with its plastic sheath to allow
a 1-1.5cm protrusion of the needle.
BOOK:
• Provides satisfactory pain relief in first stage of labor.
• Because These anesthetics are relatively short acting,
this block may have to be repeated during labor
• Fetal bradycardia is a worrisome complication that
occurs with approximately 15% of the paracervical
blocks.
• Bradycardia usually develops within 10 mins and may
last up to 30 mins.
• For these reasons, paracervical block is not used in
situations of potential fetal compromise.
B. SADDLE (SUBARACHNOID) BLOCK
• For the 2nd stage of labor
• Blocks S2, S3, and S4 or the pudendal nerve
• True saddle block is no readily achieved; some end up as low
spinal anesthesia
• Indicated for outlet forceps delivery
BOOK:
Spinal (Subarachnoid) block sa book
• Anesthetic in this block can be given as a single dose, can be
partnered with an epidural catheter as combined spinal epidural
analgesia, or can be administered as a continuous infusion.
• Injection of a local anesthetic into the subarachnoid space to
effect analgesia has long been used for delivery.
• Advantages include rapid analgesia onset, short duration of
action, and high success rate.
• The subarachnoid space during pregnancy is smaller, which
likely results from internal vertebral venous plexus
engorgement.
• Thus, in parturients, the same amount of anesthetic agent in
the same volume of solution produces a much higher blockade
than in nonpregnant women.
C. PUDENDAL BLOCK
• For the 2nd stage of labor
• Simple and safe peripheral nerve block.
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• Effective for second stage of labor, episiotomy and episiorrhaphy.
• Best done with an Iowa trumpet inducer to allow a gauge 21-23
spinal needle to protrude 1-1.5 cm.
• Fill up a 10cc syringe with 10cc of Lidocaine 1-2% or Bupivacaine
0.25% or Ropivacaine 0.2% when choosing to inject only 5cc per
side.
• Or, a 20cc syringe with 20cc of lidocaine 1% Bupivacaine 0.25%
to administer 10cc per side. Connect the needle to syringe by
Luer-lock.
• Do not refill syringe after injection. Using 5cc perse is sufficient,
effective and less painful on injection.
Steps
1. Feel for the ischial spine or for the midplane as in doing and
internal examination.
2. Use the right hand middle and index finger tips to identify the right
ischial spine.
3. While holding the syringe with the left hand, insert needle
transvaginally with its tip still drawn inside the needle
introducer.
4. Glide the needle introducer between the right index and middle
fingers.
5. This way the palpating hand is between the head of the fetus and
the syringe while the needle is directly tangentially and lateral.
6. This whole thing prevents injection into the fetal head and other
complications like laceration to adjacent tissues.
7. After the needle introducer is inserted just posterior to or
underneath the ischial spine, the needle is pushed through the
guide to the vaginal mucosa until it pierces the sacrospinous
ligament.
8. Aspirate first before administering each cc of drug to avoid toxicity
from unwanted intravenous injection.
9. Do the reverse on the other side.
BOOK:
• Pudendal nerve block is a relatively safe and simple
method of providing analgesia for spontaneous delivery
• Pudendal block usually does not provide adequate
analgesia when delivery requires extensive obstetrical
manipulation.
• Additional information:
Figure 1. Pudendal Nerve Block [Google]
VII.NEURAXIAL ANALGESIA
A. SPINAL (SUBARACHNOID) BLOCK
• Anesthetic in this block can be given as a single dose, as
combined spinal-epidural analgesia, or can be administered as a
continuous infusion.
• Advantages:
→ Rapid analgesia onset
→ Short duration
→ High success rate
Vaginal Delivery
• The first stage of labor requires a sensory block to the level of the
umbilicus (T10).
Trans # 22 Obstetric Anesthesia
• During the second stage of labor and for operative vaginal
delivery, a sensory block of S2 through S4 is usually adequate to
cover pain from perineal stretching and/or instrumentation.
• Local anesthetic agents are usually given to establish a sensory
block to the desired dermatome level.
Additional information:
• In vaginal delivery, we seldom use spinal kasi we will end up
na nagiging CS sya dahil hindi na sya magkakaroon ng
labor. So, yung spinal block naming ginagamit sya for CS
[Dr. Butaran]
• Analgesia is induced by absorption into the vascular system
(supraspinal), actions on the dorsal horns, and direct spread in
the cerebrospinal fluid to the brainstem.
• Highly-soluble solutions such as morphine, on the other hand,
provide extended analgesia (Lavoie, 2013).
• The major advantages of using such as combination are:
→ rapid onset of pain relief
→ decrease in shivering
→ less dense motor blockade
• Side effects:
→ Pruritus
→ Urinary retention
• Nalbuphine 2.5 to 5 mg IV can be used to treat pruritus without
diminishing the analgesic effect.
Cesarean Delivery
• A level of sensory blockade extending to the T 4 dermatome is
desired for cesarean delivery.
• Depending on maternal size, 1 0 to 12 mg of bupivacaine in a
hyperbaric solution or 50 to 75 mg of lidocaine hyperbaric
solution is administered.
• Addition of opioids:
→ Increase the rapidity of blockade onset
→ Reduces shivering
→ Minimizes referred pain, nausea, and vomiting
• The addition of a preservative-free morphine (Duramorph or
Astramorph), 0. 1 to 0.3 mg intrathecal or 2 to 4 mg epidural,
provides pain control up to 24 hours postoperatively.
• Bupivacaine yung nilalagay sa 10 or 5cc syringe, and then i-
position mo muna yung spinal needle mo. Kapag nailagay
mo na yung spinal needle mo saka mo introduce yung
anesthetic agent. [Dr. Butaran]
Complications of Regional Analgesia
1. Hypotension
• Common complication that may develop soon after injection
of the local anesthetic agent.
• It is the consequence of vasodilatation from sympathetic
blockade and is compounded by obstructed venous return due
to uterine compression of the great vessels.
• Treatment:
→ Uterine displacement by left lateral positioning
→ IV crystalloid hydration
→ IV bolus injection of Ephedrine or Phenylephrine
Additional information:
• Ephedrine
→ A sympathomimetic drug that binds to X- and 0-receptors
but also indirectly enhances norepinephrine release.
→ It raises blood pressure by raising heart rate and cardiac
output and by variably elevating peripheral vascular
resistance. [William’s Obstetrics]
2. High of Total Spinal Blockade
• Follows administration of excessive dose of local anesthetic
or inadverdent injection into the subdural or subarachnoid
space.
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 Additional information from William’s: Additional information from William’s:
• Subdral injection - manifests as a high but patchy block • Subarachnoid puncture – is also contraindicated if
even with a small dose of local anesthetic agent. cellulitis involves the planed needle entry site
• Subarachnoid injection - typically leads to complete spinal • Neurological disorders – exacerbation of the neurological
blockade with hypotension and apnea. disease might be erroneously attributed to the anesthetic
• These conditions must be immediately treated to prevent agent.
cardiac arrest. • Aortic stenosis
• In the undelivered women: • Pulmonary hypertension
→ Uterus is immediately displaced laterally – to minimize
B. EPIDURAL ANALGESIA
aortocaval compression
• Injection of a local anesthetic agent into the epidural or peridural
→ Effective ventilation is established – preferably with
space
tracheal intubation
• This potential space contains areolar tissue, fat, lymphatics, and
→ IV fluids and vasopressors – to correct hypotension
the internal vertebral venous plexus.
• If chest compressions are to be performed – woman is
• Complete analgesia for the pain of labor and vaginal delivery
placed in left-lateral position to allow left uterine
necessitates a block from the T10 to the S5 dermatomes.
displacement
• For cesarean delivery, a block extending from the T4 to the S1
dermatomes is desired.
3. Postdural Puncture Headache
• The effective spread of anesthetic depends on the catheter tip
• Leakage of CSF from dura mater puncture site can lead to location; the dose, concentration, and volume of anesthetic agent
postdural puncture or “spinal headache”. used; and whether the other is head-down, horizontal, or head-
Additional information from William’s: up.
• When the woman sits or stands, the diminished CSF
volume creates traction on pain-sensitive central nervous
system structures.
• Another mechanism may be the compensatory cerebral
vasodilation in response to the loss of CSF - the Monro-
Kellie doctrine (Mokri, 2001).
• Treatment:
→ Epidural blood patch – GOLD STANDARD
 10 to 20 ml of autologous blood obtained aseptically
by venipuncture is injected into the epidural space.
→ Further CSF leakage is halted by either mass effect or
coagulation.
• Ang treatment mo lang dito ay enough IV fluids [Doc Butaran]
4. Convulsions
• postdural puncture cephalgia is associated with temporary
blindness and convulsions. Figure 2. Epidural anesthesia [William’s OB]

• It is presumed that these too are caused by CSF hypotension. Doc’s Notes:
• Immediate treatment of seizures and a blood patch were • I-iinsert yung needle. Tapos, iintroduce yung catheter and is
usually effective in these cases. directed upward making sure na kapag nagrelease na ng
5. Bladder Dysfunction anesthesia, dapat maabot yung T4 dermatome. Slowly
• Bladder sensation is likely to be obtunded and bladder release lang ng anesthesia.
emptying impaired for several hours after delivery. • Itetest ng anesthesiologist kung naabot na yung T4 at kung
• Bladder distention – frequent postpartum complication na-block na ito.
especially if appreciable volumes of fluid are given. Techniques
6. Arachnoiditis and Meningitis • Informed consent is obtained, and the obstetrician consulted
• Rare • Monitoring includes the following:
Table 4. Complications of Regional Analgesia → Blood pressure every 1-2 minutes for 15 minutes after giving
Complication a bolus of local anesthetic
Not Infrequent → Continuous maternal heart rate and pulse monitoring and
Hypotension verbal communication
Fever → Continuous fetal heart rate monitoring
Postdural puncture headache • Hydration with 500-1000 mL of lactated Ringer solution
Breakthrough pain • The woman assumes a lateral decubitus or sitting position
Uncommon • The epidural space is identified with a loss-of-resistance
Inadvertent intrathecal, subdural, or intravascular injection of technique
local anesthetic drug • The epidural catheter is threaded 3-5 cm into the epidural space
Neurologic injury • A test dose of 3 mL of 1.5% lidocaine with 1:200,000 epinephrine
Absolute Contraindications to Neuraxial Analgesia or 3 mL of 0.25% bupivacaine with 1:200,000 epinephrine is
• Refractory maternal hypotension injected after careful aspiration to avert intravascular injection
• Maternal coagulopathy and after a uterine contraction
• Thrombocytopenia (variously defined) • If the test dose is negative, 10-15 mL of 0.0625-0.125%
• Low-molecular-weight heparin within 12 hours bupivacaine is injected to achieve a sensory T10 level
• Untreated maternal bacteremia • After 15-20 minutes, the block is assessed using loss of
sensation to cold or pinprick.
• Skin infection over the site of needle placement
→ Syempre pinprick tayo. Tutusukin mo yung area pataas
• Increased intracranial pressure cause by a mass lesion
hanggang sa extent ng loss of sensation. Kunwari umbilicus,
meron pa ba (pain)? Syempre, hindi dapat lalagpas sa

Trans # 22 Obstetric Anesthesia 4 of 5

 umbilicus ang anesthesia mo, kasi kung lalagpas yan di na • Patient preparation:
makakahinga si mother. → Antacid administration to avoid aspiration
• The woman is positioned in the lateral or semi-lateral position to → Uterine displacement
avoid aortocaval compression. Subsequently, maternal blood → Pre-oxygenation
pressure is recorded every 5-15 minutes. • Induction should be smooth and rapid
• The fetal heart rate is monitored continuously
• The lever of analgesia and intensity of motor blockade are X. POSTPARTUM ANALGESIA
assessed at least hourly • Goals for postoperative pain management:
Complications → Maximize patient satisfaction
1. High or total blockade → Minimize side effects
2. Ineffective analgesia → Aiding functional capacity
3. Hypotension → Preventing prolonged hospital stays
4. Fever XI. FOOTNOTES BY DOC
5. Back pain
• Ang pinakaimportante dito ay malaman niyo kung bakit kailangan
• Effect in labor – prolong the second stage by 1 hour niyong i-anesthesize si mother at kailangan niyong i-inform si
• Timing of placement – no increased risk on operative delivery patient kung bakit gagawin ‘yon.
• For cesarean section, better na si Anesthesiologist ang mag-
Contraindications inform at mag-explain kay patient
1. Thrombocytopenia
2. Anti-coagulation XII.REFERENCES
3. Severe eclampsia/pre-eclampsia • Doc Butaran’s Youtube Video (PPT)
Other Techniques • William’s Obstetrics 24th edition
• William’s Obstetrics 25th edition
• Combined Spinal-Epidural Analgesia
• Continuous spinal analgesia during labor
VIII. LOCAL INFILTRATION FOR CESAREAN SECTION
• During the early days lang ginagawa ito, ngayon rarely na lang.
• Local anesthetic block for cesarean delivery
• The first injection site is halfway between the costal margin and
iliac crest in the midaxillary line to block the 10th, 11th, and 12th
intercostal nerves
• A second injection at the external inguinal ring blocks branches
of the genitofemoral and ilioinguinal nerves
• These two sites are infiltrated bilaterally
• The third and final site is along the line of proposed skin incision
IX. GENERAL ANESTHESIA FOR CESAREAN SECTION
• As safe and effective as regional anesthesia
• High aspiration risk of stomach contents, trauma to underlying
tissues during intubation, and other problems of ventilation
• Indicated to either stat CS or non-reassuring fetal status, when
RA is contraindicated or as per patient’s choice
• Objectives:
→ Prevent pulmonary aspiration
→ Avoid uterine atony
→ Provide intraoperative anesthesia that extends to post-
operative relief
→ Maintain the mother-baby friendly initiative
Doc’s Notes:
• So, sa general anesthesia, ang patient sinesedate, may
binibigay na pampatulog. Tapos iniintubate para masecure
yung airway.

Trans # 22 Obstetric Anesthesia 5 of 5