Anaesthesia and Analgesia in

Labour

Brett Johnson
Vadewattie Ramnarine
Anna Singh
Gabrielle De Nobrega
Bhavanie Singh
Maternal Anatomy
Mons pubis
- Fat filled cushion that
lies over the symphysis
pubis
- After puberty, covered
by curly hair called the
escutcheon
- Women– triangular
- Men – not well
circumscribed
Labia Majora
- Homologous with the male
scrotum
- Round ligament terminates
at the upper border
- Merge posteriorly to form
the posterior commissure
- Puberty covered with hair
- Richly supplied with
sebaceous glands and
plexus of veins
Labia Minora
- Supplied with a variety
of nerve endings and
are very sensitive
- Merge anteriorly into 2
lamellae:
- lower- frenulum
- upper – prepuce
- Posteriorly fuse to form
fourchette
Clitoris
- Principal female
erogenous organ
- Homologue of the penis
- Composed of glans,
corpus, and 2 crura
- Vessels are connected
with the vestibular
bulbs
Vestibule
- Almond shaped area
enclosed by labia
minora laterally and
extends from the
clitoris to fourchette
- Peforated by 6 openings
Vestibule
Vestibular Bulbs
- Correspond to the anlage of
the corpus spongiosum of
the penis
- Almond-shaped
aggregations of veins that
lie beneath the mucous
membrane on either side of
the vestiblue
Perineum
- Support:
- pelvic diaphragm consists
of levator ani M and
coccygeus M posteriorly
- urogenital diaphragm made
up of deep transverse
perineal M, constrictor of
urethra, int. & ext. fascial
coverings
Uterus
- Posterior wall covered by
serosa
- Forms the Pouch of Douglas
- Upper ant. Wall covered by
seosa, lower united with
post. Wall of bladder by
loose connective tissue
- Resembles a flattened pear
Uterus
- 2 parts;
- upper triangular-
corpus or body
- lower cylindrical- cervix

- isthmus- portion
between internal os and
endometrial cavity
Uterus
1. Cornua- portion were oviduct
emerges
2. Fundus – convex upper
segment above cornua
3. Round ligament – insert below
the tubes
4. Broad ligament – fold of
peritoneum extending to
pekvic side walls
5. Uterosacral ligament –
posterior to the uterus
Uterus
Cervix
- Internal os- level at which
peritoneum reflects upos
the bladder
- Portio vaginalis- lower
vaginal portion
- Nabothian cysts- occluded
cervical glands
Uterus
Endometrium
- Epithelium made up of
single layer high
columnar ciliated cells
- Invaginations form the
tubular uterine glands
Uterus
Blood Supply
- Internal iliac A 
uterine A & ovarian
A(aorta) arcuate A 
radial A coiled or
spiral A (endometrium)
- supply midportion &
superficial third of the
endometrium
Uterus
Blood Supply
- Lateral to cervix,
uterine A crosses over
the ureter
- of significance during
hysterectomy
Uterus
Myometrium
- Makes up the major
portion of the uterus
- Smooth M
- Thicker in the inner
layers
Uterus
Ligaments
1. Broad ligament- wing-like
structure
- mesosalpinx- inner 2/3
where fallopian tubes are
attached
- infundibulopelvic
ligamentor suspensory
ligament of the ovary-
ovarian vessels traverse
Uterus
2. Cardinal Ligament –
transverse cervical
ligament, Mackenrodt
ligament
- thick base of the
broad ligament united
with the supravaginal
portion of the cervix
Uterus
3. Round Ligament
- terminates in the
upper portion of the
labia majora
- corresponds with the
gubernaculum testis
Uterus
4. Uterosacral Ligament
- from the supravaginal
portion of the uterus
and attaches to the
fascia over the sacrum
- form the lateral
boundaries of the Pouch
of Douglas
Oviducts
- Fallopian tubes
- 4 portions:
1. Interstitial-within the
muscular wall of uterus
2. Isthmus- narrow portion
3. Ampulla- wide lateral
portion
4. Infundibulum- fimbriated
end, funnel-shaped
opening
Oviduct
- Lined by a single layer
of columnar cells some
ciliated, others
secretory
- Musculature- inner
circular , outer
longitudinal
- Major innervation is
sympathetic
Ovaries
- Size in the childbearing
years:
- length: 2.5-5 cm.
- width: 1.5-3 cm.
- thickness: 0.6-1.5 cm.
- Ovarian fossa of waldeyer-
slight depression on the
lateral wall of pelvis for
ovaries
Ovaries
- Attached to broad
ligament by mesovarium
- Utero-ovarian ligament-
just below interstitium to
ovary
- Infundibulopelvic or
suspensory ligament of
the ovary- to the pelvic
wall; through it course
the vessels and nerves
Ovaries
- 2 portions:
1. Cortex- outer layer
- connective tissue cells
where primodial and
graafian follicles are
scattered
- outer portion- tunica
albuginea lined by a single
layer of cuboidal
epithelium, germinal
epithelium of Waldeyer
Ovaries
2. Medulla – central
portion
- composed of loose
connective tissue
continuous with the
mesovarium
- with arteries and
veins, with small
amount of M fibers
The Bony Pelvis
The Bony Pelvis
- Composed of the sacrum,
coccyx, and 2 innominate
bones
- Innominate bone formed by
the fusion of the ilium,
ischium, and pubis
- Joined to the sacrum by
sacroiliac synchondrosis and
to one another at the
symphysis pubis
Pelvic anatomy
- False pelvis lies above the
linea terminalis
- True pelvis below this
boundary
- important in childbearing
- ishial spines- its distance
represents the shortest
pelvic diameter
- landmark for
assessing level of presenting
part
 Planes and Diameters of the Pelvis
Four Imaginary Planes:
1. Plane of the Pelvic inlet – superior strait
2. Plane of the Pelvic Outlet – inferior strait
3. Plane of the Midpelvis – least pelvic dimensions
4. Plane of the Greatest Pelvic Dimension – no
obstetrical significance
Pelvic Inlet
Pelvic Inlet
- 50% of women
with a gynecoid
pelvic inlet
- 4 diameters:
 Pelvic Inlet
1. Anteroposterior diameter:
- shortest distance between the promontory
and the symphysis pubis
- obstetrical conjugate
- normally measures 10 cm. or more
- clinical measurement of the obstetrical
conjugate s done by subtracting 1.5-2 cm. from
the diagonal conjugate
 Pelvic Inlet
2. Transverse diameter
- at right angles to the obstetrical conjugate
- greatest distance between the linea terminalis on
either side :13.5 cm.

3. 2 Oblique diameters
- from the sacroiliac synchondrosis to the
ileopectineal eminence: 13 cm.
 Midpelvis
- Measured at the level
of the ischial spine
- Interspinous diameter :
10 cm. or more,
smallest diameter of
the pelvis
Pelvic Outlet
- Three diameters:
- anteroposterior
- transverse: between
the ischial tuberosities :
11cm.
- posterior sagittal
Pelvic Shapes
Pelvic Shapes
1. Android : anterior portion
is narrow and triangular

2. Platypelloid : flattened
gynecoid pelvis
- short anteroposterior,
wide transverse
Pelvic Shapes
3. Gynecoid
- found in 50% of women
- most suitable for delivery
of the fetus
4. Anthropoid
- anteroposterior
diameter is greater than
the transverse
- found in 1/3 of women
Maternal Physiology
 Uterus
- During pregnancy, it is transformed into a thin-
walled organ sufficient to accommodate the fetus,
placenta, and amniotic fluid
- Non-pregnant Pregnant
Volume: 10 ml cavity 5- 20 L
Weight: 70 g 1100 g
- Uterine enlargement involves stretching and marked
hypertrophy of muscle cells
- stimulated by estrogen and some progesterone
influence
 Uterus
- Arrangement of Muscle cells:
1. Outer hoodlike layer- arches over the fundus
and extends into the ligaments
2. Middle layer – dense network of M fibers
perforated in all direction by blood vessels
3. Internal layer – sphincter-like fibers around the
orifice of the fallopian tubes and the internal os
of the cervix
 Uterus
- Braxton Hicks contraction – painless uterine
contraction in a normal pregnancy
- Uteroplacental Blood Flow- delivers most
substances essential for growth and
metabolism
 Cervix
- During pregnancy, the cervix undergoes softening
and cyanosis due to increased vascularity and edema
- Mucus plug – copious amount of mucus produced to
obstruct the cervical canal
- Bloody show- expulsion of the mucus plug
- cervical mucus beading in pregnancy due to
progesterone
- Ferning- amniotic fluid leakage
 Ovaries
- Ovulation ceases and maturation of new
follicles is suspended in pregnancy
- Corpus luteum- maximally functions in
progesterone production in the 1st 6-7 wks. of
pregnancy
- Luteoma of pregnancy – solid ovarian tumors
produced due to exaggerated luteinization
reaction
 Ovaries
- Theca-lutein Cysts – benign ovarian lesions
resulting from exaggerated physiological
follicle stimulation
- associated with markedly elevated serum
hCG levels
 Fallopian Tubes
- Musculature undergoes hypertrophy

- Epithelium of tubal mucosa becomes flattened

 Vagina and Perineum
- Chadwick sign- violet discoloration due to
increased vascularity
- Changes in preparation for distention:
1. increase thickness of mucosa
2. Loosening of connective tissue
3. Hypertrophy of smooth M cells
 Abdominal wall
- Striae gravidarum- “stretch marks”
- reddish, slightly depressed
streaks

- Diastasis recti- rectus M separated at midline

 Pigmentation
- Linea nigra – markedly pigmented midline of
linea alba

- Chloasma/melasma gravidarum – irregular

brownish patches on the face and neck
 Vascular Changes
- Vascular spiders – minute red elevations on
the skin, face, neck upper chest and arms

- Palmar erythema- no clinical significance and

disappear shortly after pregnancy
 Breasts
- Early weeks – breast tingling and tenderness
- Second month- increase in size, veins become
visible, nipple become larger, darker and more
erectile
- Colostrum – thick yellowish fluid
- Glands of Montgomery – small elevations on
the broader and darker areols
 Weight gain
- Attributed to the uterus and its contents,
breasts, increase in blood volume and
extracellular fluid

- Average wt. gain: 12.5 kg. or 27.5 lbs.

 Water Metabolism
- Increased water retention

- At term, water content of fetus, placenta, and

amniotic fluid : 3.5 l

- Increased blood volume and size of uterus and

breasts : 3.0 l

- The total amount 6.5 ml

 Protein Metabolism
- At term, fetus and placenta weigh 4 kg. with
500 g of protein

- Nitrogen balance increases with gestation

 Carbohydrate Metabolism
- Mild fasting hypoglycemia, postprandial
hyperglycemia, hyperinsulinemia

- Increased basal level of plasma insulin

 Fat Metabolism
- Concentration of lipids, lipoprotein,
apolipoproteis in plasma increase

- LDL increases may be attributed to estrogen

- Fat usually deposited in the central rather

than peripheral sites
 Electrolyte and Mineral Metabolism
- 1000 meq of Na and 300 meq of K are
retained in pregnancy

- Total Ca and Magnesium levels decrease

 Blood Volume
- Increases to 40-45% above non-pregnant levels
- Functions of prenancy-induced hypervolemia:
1. Meet demans of enlarged uterus
2. Protect mother and fetus against deliterious effects
of impaired venous effects in the supine and erect
position
3. Safeguard the mother against the adverse effects
of blood loss associated with parturition
 Iron Metabolism
- Total iron requirement: 1000 mg

- Amount of iron absorbed from the diet and

that mobilized from stores is insufficient to
meet maternal demands
- Supplemental iron is necessary
- Blood loss: Normal delivery: 500 ml
- cesarean delivery: 1000 ml
 Heart
- Resting pulse rate increases by 10 beats/min.
- Cardiac sounds: exaggerated splitting of the
1st heart sound, increased loudness of both
sounds
- Systolic murmur noted in 90% of pregnant
women
 Heart
- Cardiac Output: increased in early pregnancy
- much greater in the 2nd stage of
labor

- Increase is lost immediately after delivery

 Circulation and Blood Pressure
- Arterial BP decreases to a nadir at
midpregnancy and rises thereafter
- In late pregnancy, blood flow at the lower
extremities is retarded due to occlusion of the
pelvic veins and inferior vena cava
- Supine hypotensive syndrome- due to
compression of venous system from enlarging
uterus
 Pulmonary Function
- Respiratory rate is not changed
- Increased functions:
- tidal volume
- minute ventilatory volume
- minute oxygen uptake
- Decreased functions:
- functional residual capacity
- residual volume
 Acid-Base Equilibrium
- Increased tidal volume lowers blood PCO2

- Induced by progesterone mainly

- Respiratory alkalosis stimulated the increased

affinity of maternal hemoglobin for oxygen
(Bohr effect)
 Kidney
Renal Changes:
1. Kidney size increases
2. Glomerular filtration rate and renal plasma
flow increases early
3. Dilatation of pelves, calyces, ureter
4. Renal bicarbonate threshold decreases
5. Osmoregulation is altered
 Ureters
- More ureteral dilatation on the R due to:
- cushioning on the L by sigmoid
- dextrorotaiton of he uterus

- Progesterone may contribute to ureteral

dilatation
 Bladder
- Some women develop stress urinary
incontinence

- Few anatomic changes noted- deepening and

widening of trigone
- Stomach and intestines are displaced by the
enlarging uterus
- Pyrosis (heartburn)- common during
pregnancy, caused by reflux of acidic
secretions
- Epulis - hyperemic and softened gums
- Hemorrhoids – due to constipation and
elevated pressure in veins
Liver
- Concentration of serum albumin decreases
- Leucine aminopeptidase activity is elevated –
has oxytocinase activity

Gallbladder
- Decreased contractility due to progesterone
• Please visit:

http://crisbertcualteros.page.tl
Analgesia in Labour

Vadewattie Ramnarine
 Analgesia for labour

• Maternal satisfaction in labour is multifactorial. While analgesia in

labour is important to many women, it is not a requirement for a
positive experience of childbirth.

• Various coping strategies and support methods are available,

including prepared childbirth, support from a partner, known
midwife or ‘doula’ (a senior female companion who is experienced
in childbirth), water baths, aromatherapy, and massage. These can
greatly increase maternal satisfaction.
Consent
• Most anaesthetists do not take written consent before inserting an
epidural for labour analgesia, but ‘appropriate’ explanation must be
given.
• Uterine contractions and cervical dilatation result in
visceral pain. These pain impulses are transmitted by
afferent, slow conducting, A-delta and C fibers that
accompany the sympathetic nerves and enter the spinal
cord at the T10 to L1 level.

• As labor progresses, the descent of fetal head and

subsequent pressure on the pelvic floor, vagina, and
perineum, generates somatic pain, which is transmitted by
the pudendal nerve (S2-4). These rapidly conducting
somatic pain fibers are relatively difficult to block.

• In obstetric patients, regional analgesia refers to partial or

complete loss of pain sensation below the T8 to T10 spinal
level.
 Goals of labour analgesia
• Dramatically reduce pain of labor
• Should allow parturients to participate in birthing
experience
• Minimal motor block to allow ambulation
• Minimal effects on fetus
• Minimal effects on progress of labor
 Indications for regional labour
analgesia
• Maternal request.
• Expectation of operative delivery (e.g. multiple pregnancy,
malpresentation).
• Specific cardiovascular disease (e.g. regurgitant valvular
lesions, myocardial ischaemia).
• Severe respiratory disease (e.g. cystic fibrosis).
• Specific neurological disease (intracranial AV
malformations, space occupying lesions, etc.).
• Obstetric disease (e.g. pre-eclampsia).
• Conditions in which general anaesthesia may be life-
threatening, particularly if rapid regional anaesthesia may
be difficult to institute (e.g. morbid obesity).
 Contraindications for regional labour
analgesia
• Maternal refusal.
• Allergy (true allergy to amide local
anaesthetics is rare so always take a careful
history).
• Local infection.
• Uncorrected hypovolaemia.
• Coagulopathy.
 Relative contraindications for regional
labour analgesia
• Expectation of significant haemorrhage.

• Untreated systemic infection.

• Specific cardiac disease (e.g. severe valvular stenosis, Eisenmenger's

syndrome, peripartum cardiomyopathy). Although regional analgesia has been
used for many of these conditions, extreme care must be taken to avoid any
rapid changes in blood pressure, preload, and afterload of the heart.
Intrathecal opioid without local anaesthetic may be advantageous for these
patients.

• Bad backs and previous back surgery do not contraindicate regional

analgesia/anaesthesia, but scarring of the epidural space may limit the
effectiveness of epidural analgesia and increase the risk of inadvertent dural
puncture. Intrathecal techniques can be expected to work normally.
 Techniques of labor analgesia
• Continuous epidural analgesia
• Intermittent epidural bolus injections
• Patient-controlled epidural analgesia (PCEA)
• Combination of the above two techniques
• Combined spinal-epidural analgesia (CSE)
• Spinal opiates
• Continuous spinal analgesia
 Neuraxial opioids
The following opioids have been used: Morphine,
fentanyl, sufentanil, meperidine, methadone,
diamorphine, butorphanol
Side effects: Pruritus, nausea and vomiting,
hypotension, respiratory depression (first two hrs-
fentanyl, sufentanil; up to 16 hrs with morphine),
urinary retention, delayed gastric emptying,
reactivation of herpes simplex virus, fetal bradycardia
from uterine hyperstimulation (no increased
incidence of cesarean section)
 Epinephrine
• Epinephrine, an adrenergic agonist, is sometimes added at a
concentration of 1:200,000 to 1:800,000 to the solution of local
anesthetics for epidural analgesia but not for intrathecal analgesia.

• Epinephrine hastens the onset of analgesia and increases its

duration of action. Thus, it decreases the requirement of higher
concentration of local anesthetics.

• Unfortunately, when local anesthetics are used in combination with

epinephrine, they are more highly associated with motor block,
even if the concentration of the local anesthetic is unchanged. This
higher association with motor blockage and its potential tocolytic
effects has made epinephrine less popular for neuroaxial use.
 Equipment

• Crystalloid, 500-1000 mL
• Equipment to monitor blood pressure, maternal heart rate, and fetal heart rate
• Drapes, antiseptic
• Epidural needle, 17-18 gauge (ga)
• Epidural catheter
• Anesthetic
• Preservative-free saline, 3-5 mL
• Single-orifice or multiple-orifice catheter.
– The proposed advantage of single-orifice, open-ended catheters is that the injection of drugs
is restricted to a single anatomical site. In theory, this should facilitate the detection of
intravenous or subarachnoid placement of catheter. Likewise, the purported disadvantage of
multiple-orifice, closed-end catheters is that local anesthetic may be injected into more than
one anatomical site.
– However, increasing evidence suggests that multiple-orifice, closed-end catheters result in a
more even distribution of local anesthetic and a greater likelihood of successful epidural
anesthesia.
– Modern catheters (single- and multiple-orifice) are soft, flexible, and reliable, so there are no
compelling reasons to favor one over another, provided the anesthesiologist pays careful
attention to detail during the injection of local anesthetic.
 Technique
• The preanesthetic evaluation.
• Although intravenous fluid preloading may be used to reduce the
frequency of maternal hypotension, initiation of regional analgesia
should not be delayed to administer a fixed volume of intravenous
fluid.
• An intrapartum platelet count for patients with severe
preeclampsia, HELLP syndrome, idiopathic thrombocytopenic
purpura, known placental abruption, or other risk factors for
disseminated intravascular coagulation.
• A routine blood crossmatch e.g in anticipated hemorrhagic
complications.
• The oral intake of modest amounts of clear liquids may be allowed
for uncomplicated laboring patients. Patients with additional risk
factors for aspiration (e.g, morbid obesity, diabetes, difficult airway)
or patients with increased risk for operative delivery may have
further restrictions of oral intake, determined on a case-by-case
basis. Solid foods should be avoided in all laboring patients.
 Positioning

• Pregnant women have exaggerated lumbar

lordosis which makes it more difficult for them
to flex the lumbar spine. However, as most
pregnant women are relatively young, their
spines have sufficient flexibility to facilitate
the insertion of a needle into the epidural or
subarachnoid space.
Lumbar lordosis of pregnancy.
• Regional anesthesia can be administered with the patient in either
a seated or lateral decubitus position.

• The seated position is especially preferred for obese patients and to

facilitate instrument delivery. Its advantages include facilitating
identification of the spinous process, providing better respiratory
mechanism, and improving maternal comfort. However, the seated
position is more likely associated with an increased incidence of
orthostatic hypotension. An assistant often is required while using
the seated position.

• The advantages of lateral positioning include better uteroplacental

perfusion, lower likelihood of orthostatic hypotension, and
facilitation of fetal heart rate monitoring during placement of the
epidural catheter. In addition, some patients find this position more
comfortable.
• When administering a spinal block while the patient is in lateral
position, injecting local anesthetic with the patient lying on her
right side makes sense because she will be tilted leftward
thereafter. If the local anesthetic is injected with the patient lying
on her left side, and the leftward tilt is maintained thereafter, an
asymmetric inadequate block may result.

• Posture has less influence on the spread of epidural anesthesia.

During epidural anesthesia, a unilateral block more often results
from malposition of the catheter than from prolonged use of one
position.

• Aortocaval compression must be avoided at all times. The gravid

uterus can occlude the inferior vena cava and aorta when the
parturient assumes the supine position. This can decrease
uteroplacental perfusion, even in the absence of anesthesia.
The 3 major subtypes of regional block are epidural, combined spinal/epidural (CSE), and

spinal. Of these, the epidural technique is most preferred for labor analgesia .
 Epidural analgesia
• Epidural analgesia is the most effective form of pain relief in labor and is used by most
laboring women in United States. It has 4 subtypes.
• Single epidural shot- is short lasting, insertion of an epidural catheter is not necessary for
this technique.
• Intermittent bolus-This technique has 2 limitations. First, if injections are not administered
until pain returns, the parturient experiences intervals of analgesia after the dose takes effect
alternating with intervals of pain as the analgesia wanes. Secondly, intermittent dosing
requires frequent provider intervention.
• Continuous infusion epidural-avoids the peaks and valleys of intermittent administration and
results in a smoother analgesic experience for the parturient with fewer provider
interventions, associated with less motor block and hypotension. The infusion may be
adjusted to individualize analgesia, and additional rescue doses may be administered, as
needed. In addition, the epidural catheter can also be used if a larger dose of local anesthetic
is needed for instrumental or cesarean delivery or for pain control postpartum.
• Patient-controlled epidural analgesia (PCEA)-PCEA differs from the continuous infusion
technique in that the parturient herself is given the means to fine-tune the dose of analgesic
she receives. This gives the parturient the psychological advantage of being in control of her
own therapy. This technique is best reserved for patients who are willing and able to
understand that they are in control of their analgesia.
 Epidural analgesia administration
• Obtain informed consent.
• Ensure adequate venous access.
• Prehydrate with 500-1000 mL of crystalloid.
• Set up patient monitoring as follows:
• Blood pressure recording at baseline prior to administration of
regional anesthetics; then every 1-2 minutes for 15 minutes
after giving a bolus of local anesthetic; then at every 5-15
minute interval until the block wears off
• Continuous maternal heart rate monitoring during induction
of analgesia
• Continuous fetal heart rate monitoring
• Help the patient assume a seated or lateral decubitus position.
The seated position is preferred in very obese patients.
• Clean the lumbar area with appropriate antiseptic and drape the area.
• Palpate the lumbar spinous process and choose the widest interspace below L3.
• Place a hollow epidural needle (17 or 18 ga) in the intervertebral ligaments.
• These ligaments are characterized by a high degree of resistance to penetration.
• Connect a syringe to the epidural needle. Resistance upon injection confirms
placement in the ligaments.
• Slowly advance the needle while feeling for resistance. A sudden loss of resistance
is felt as the epidural needle enters the epidural space.

• Aspirate for blood or cerebrospinal fluid (CSF).

• Most anesthesiologists insert the catheter before injecting the therapeutic dose of
local anesthetic so that correct catheter placement can be verified promptly. If this
catheter technique is chosen, administer 3-5 mL of preservative-free normal saline
or dilute local anesthetic to facilitate passage of the catheter. Some
anesthesiologists contend that this expands the epidural space and decreases the
likelihood of unintentional intravenous cannulation of the catheter.
• Advance an epidural catheter into the epidural space.

• To minimize the risk of catheter displacement, especially in obese

patients, insert the catheter at least 4 cm into the epidural space.

• Shallow placement (2 cm for single-orifice catheters; 3 cm for

multiple-orifice catheters) increases the likelihood of block failure.
Deep placement increases the chance of intravenous placement,
unilateral block, or both.

• Withdraw the needle over the tubing.

• After careful aspiration and uterine contraction, inject a test dose

of 3 mL of lidocaine 1.5% with epinephrine 1:200,000 or 3 mL of
bupivacaine 0.25% with epinephrine 1:200,000. This minimizes the
chance of confusing tachycardia caused by labor pain with
tachycardia caused by intravenous injection of the test dose.
• If the test dose is negative (i.e, absence of tachycardia),
inject the anesthetic in 2-3 small boluses to achieve a
cephalad sensory level of approximately T10. Initial block
options include the following:
• Bupivacaine 0.125-0.25% (10-15 mL)
• Bupivacaine 0.125% (10-15 mL) with fentanyl 50-100 mcg
• Fentanyl 50-100 mcg (or sufentanil 10-15 mcg) in 10 mL
normal saline

• After 15-20 minutes, assess sensation using loss of

sensation to cold or pinprick.
• If no block is evident, replace the catheter.
• If the block is asymmetrical, withdraw the catheter 0.5-1
cm and inject an additional small dose of the anesthetic.
• If the block remains inadequate, replace the catheter.
• When loss of sensation is confirmed, secure the catheter to the patient’s
back with adhesive dressing.

• After administration of analgesic, position the patient in a lateral or

semilateral position to avoid aortocaval compression.

• Solutions of a local anesthetic, opioids, or a combination of the two can

now be administered through the catheter. Aspirate the catheter for blood
or CSF before each top-up dose. Subsequent analgesia options include:

• Repeated intermittent boluses as necessary to maintain maternal comfort

• Continuous infusion of 10-15 mL/h of one of the following:Bupivacaine

0.0625-0.125% with fentanyl 1-2 mcg/mL (or sufentanil 0.1-0.3 mcg/mL)
• Bupivacaine 0.125-0.25% without opioids
• Addition of epinephrine 1:400,000 (2.5 mcg/mL) to either of above
• Assess the level of analgesia and intensity of motor block at least
hourly. Development of motor block may indicate subarachnoid
migration. Verify catheter location by aspiration, careful sensory
motor examination, and, if necessary, cautious administration of a
test dose.

• Achieving adequate perineal analgesia is especially important in

women in whom episiotomy or the application of forceps is
probable.

• Women who progress into the second stage of labor soon after
induction of epidural analgesia seldom have adequate sacral
blockade and often require additional epidural boluses of local
anesthetic before delivery. On the other hand, women who have
been receiving continuous epidural analgesia for many hours often
have excellent perineal analgesia at delivery.

• Reports of rectal pressure with progressive descent of the fetal

head may indicate that sacral analgesia is inadequate for delivery.
• If perineal anesthesia is required, administer 10-15 mL of local anesthetic
such as lidocaine.

• Be aware that the incidence of third- and fourth-degree perineal

laceration is increased in patients who receive epidural analgesia (odds
ratio.
• When epidural analgesia is discontinued, remove the catheter with
utmost care. If resistance is encountered while removing the catheter, the
patient should assume a position that reduces lumber lordosis. This often
lessens the kinking of the catheter between perivertebral structures.

• Following successful catheter removal, ensure that the tip is present,

indicating complete removal. If the catheter breaks, leaving part of the
catheter in the patient, some physicians may favor aggressive attempts to
remove the broken catheter but most do not.
 Combined spinal/epidural analgesia

• The combined spinal/epidural method has recently gained

increased popularity. It is otherwise called the needle-through-
needle or coaxial technique.

• This technique comes into play in specific circumstances, such as

late first stage or second stage of labor, where the prolonged
latency of epidural analgesia may be unacceptable.

• Advantages of this method include rapid and effective analgesia,

no increase in adverse effects, continued ambulation during labor
(in up to 80% of women) because not associated with impaired
equilibrium, low incidence of hypotension, and a combination of
the benefits of spinal and epidural blocks.
 Combined spinal/epidural analgesia administration
• This technique avoids multiple skin punctures.
• Obtain informed consent.
• Assure adequate venous access.
• Prehydrate with 500-1000 mL of crystalloid.
• Set up patient monitoring as follows:
• Blood pressure recording at baseline prior to administration of regional
anesthetics; then every 1-2 minutes for 15 minutes after giving a bolus of local
anesthetic; then at every 5-15 minute interval until the block wears off
• Continuous maternal heart rate monitoring during induction of analgesia
• Continuous fetal heart rate monitoring
• Help the patient assume a seated or lateral decubitus position. The seated
position is preferred in very obese patients.
• Clean the lumbar area with appropriate antiseptic and drape the area.
• Palpate the lumbar spinous process and locate the L3-4 or L4-5 spinal level.
• Place a hollow epidural needle (17 or 18 ga) in the intervertebral ligaments.
• These ligaments are characterized by a high degree of resistance to penetration.
• Connect a syringe to the epidural needle. Resistance upon injection confirms
placement in the ligaments.
• Slowly advance the needle while feeling for resistance. A sudden loss of
resistance is felt as the epidural needle enters the epidural space.
• Place a long spinal needle (≤24 ga and ≥124 mm) into the subarachnoid
space through the epidural needle.
• The spinal needle should extend 10-15 mm beyond the tip of the epidural
needle. The spinal needle can be used to confirm the position of epidural
needle, which may help prevent unintentional dural puncture with the
epidural needle.
• Withdraw the spinal needle after a single bolus of opioid into the
subarachnoid space. In this bolus, the opioid is sometimes in combination
with a local anesthetic.
• Place an epidural catheter to permit administration of continuous or
repeated doses of analgesics.
• For labor analgesia, an opioid such as fentanyl 10-25 mcg or sufentanil
2.5-10 mcg may be injected alone or with a local anesthetic such as
isobaric bupivacaine 1-2.5 mg into the intrathecal space. This
combination of fentanyl with bupivacaine provides analgesia for
approximately 90 minutes.
• If prolonged analgesia is indicated, after the effects of spinal drugs wear
off, initiate an epidural infusion with a bolus of bupivacaine 0.0625-0.125%
with fentanyl (2 mcg/mL) or an equivalent dose of ropivacaine.
 Spinal analgesia
• Spinal (.ie, subarachnoid, intrathecal) block is used less often than
epidural block for labor analgesia because it is short-lasting and can’t
extend the duration of action. It does have certain advantages over
epidural analgesia, including a short procedure time, rapid onset of the
block, and high success rate.
• Spinal block plays a role for procedures of limited duration, such as
forceps or vacuum delivery, or for patients already in advanced labor.
• Spinal analgesia administration
• Obtain informed consent.
• Assure adequate venous access.
• Prehydrate with 500-1000 mL of crystalloid.
• Set up patient monitoring as follows:
• Blood pressure recording at baseline prior to administration of regional
anesthetics; then every 1-2 minutes for 15 minutes after giving a bolus of
local anesthetic; then at every 5-15 minute interval until the block wears
off
• Continuous maternal heart rate monitoring during induction of analgesia
• Continuous fetal heart rate monitoring
• Help the patient assume a seated or lateral decubitus position. The seated
position is preferred in very obese patients.
• Clean the lumbar area with appropriate antiseptic and drape the area.
• For the spinal block, the subarachnoid space can be entered by either a
midline or a paramedian approach. For most patients, the midline
approach is faster and less painful than the paramedian approach.
Nevertheless, the paramedian approach is a useful technique that allows
successful identification of the subarachnoid and epidural spaces in
difficult cases. The more commonly practiced midline approach requires
the patient to reduce the lumbar lordosis to allow access to the
subarachnoid space between adjacent spinous processes (usually L2-3 or
L3-4).
• Inject local anesthetic both intradermally and subcutaneously at this site.
• Insert the introducer needle, directed midline, into the substance of the
interspinous ligament.
• Hold the introducer steady with one hand while the other hand holds the
spinal needle like a dart. Use the fifth finger as a tripod against the
patient’s back to prevent patient movement from causing the needle to
insert to a level deeper than intended.
• The introducer needle allows more accurate introduction of the spinal needle than
is possible with use of a small gauge spinal needle alone. Most anesthetists use a
24- to 27-ga spinal needle, preferably the pencil point needles (eg, Whitacre,
Sprotte), to avoid postdural puncture headache (PDPH). These pencil point needles
may be inserted without attention to the dural fiber direction.

• Note the sudden loss of resistance as the needle passes through the ligamentum
flavum and the dura.
• Remove the stylet. CSF is expected to appear in the needle hub.
• If it does not, rotate the needle in 90° increments until CSF appears.
• If CSF does not appear in any quadrant, replace the stylet, advance the needle a
few more millimeters, and check again for CSF flow.
• If CSF still does not appear and the needle is at an appropriate depth for the
patient, withdraw both the needle and the introducer and repeat the process.
• The most common reason for lack of CSF flow is insertion of the needle away from
the midline. Significant pain often suggests this incorrect placement of needle.
Indeed, a patient often indicates that the pain is located on either the left or right
side of the back. In such cases, correct direction of the needle should be
confirmed. Redirection of the needle often eliminates the patient’s pain and
results in the successful identification of the intrathecal space.
• Once CSF is freely dripping from the needle hub, use the dorsum of the
nondominant hand to steady the introducer and the spinal needle against the
patient’s back while the syringe with local anesthetic is attached to the needle.
• Aspirate to ensure free flow of CSF.
• Inject the anesthetic drug at a rate of 0.2 mL/s.
• Usual spinal block is achieved by injecting 25-50 mg of hyperbaric lidocaine or 5-
7.5 mg of hyperbaric bupivacaine into the subarachnoid space. Fentanyl 10-25
mcg may also be added to the spinal anesthetic.
• Anesthetic drugs are preferably administered after a uterine contraction to
decrease the likelihood of unexpected high block.
• After the completion of injection, again aspirate approximately 0.2 mL of CSF and
reinject that CSF back into the intrathecal space. This last step reconfirms the
needle location and clears the needle of the remaining local anesthetic.
• Position the patient as appropriate. A dorsal supine position with a leftward tilt is
preferred.
• The level of spinal block is usually complete and fixed in 5-10 minutes, but it may
continue to creep upward for up to 20 minutes.
 Complications
• Serious toxicity from labor analgesia usually follows inadvertent intravenous
injection, but it also may be induced by administration of excessive amounts of
anesthetic. It generally manifests in the central nervous and cardiovascular
systems. For both systems, the early symptoms are those of stimulation followed
by depression as blood levels rise.
• If the test dose is injected intravascularly, the lidocaine produces tinnitus,
circumoral numbness, metallic taste, and dizziness, and the beta1-adrenergic
agonist effect of epinephrine results in tachycardia. The tachycardia (heart rate
increase by 10 bpm) is seen within 60 seconds of the test dose and lasts for nearly
60 seconds. The subjective sensation of palpitation itself is also a reliable symptom
of intravascular administration, irrespective of the monitored heart rate. However,
the wide variations in heart rate that occur with labor pain may mask epinephrine-
induced increases in heart rate. Thus, to maximize sensitivity, the test dose should
be administered immediately after a uterine contraction.
• Intrathecal injection of the test dose causes rapid onset of dense lower extremity
motor block and sacral analgesia. For assessment of motor function of lower
extremity, some recommend a straight-leg raising test 4 minutes after the
injection of test dose.
• Air may be used for the test dose as an alternative to local anesthetic with
epinephrine. Intravascular injection of 0.5-1 mL of air is easily confirmed
by a characteristic swishing sound heard during Doppler monitoring of the
maternal precordium. This technique may be useful in selected patients in
whom even small amounts of intravenous epinephrine are
contraindicated. Aspiration alone is not a reliable method for checking
correct placement.
• Cardiovascular toxicity may include hypertension, tachycardia, cardiac
arrhythmia, cardiac arrest, or (commonly) hypotension. Hypotension, a
common complication, develops soon after injection of local anesthetics.
In patients with diminished intravascular volume (eg, preeclampsia,
antepartum bleeding, dehydration) regional block is more highly
associated with hypotension. Use of opioids alone usually does not
produce hypotension. Recent use of ultra low dose of local anesthetics
has lowered the incidence of hypotension.
• The precise definition of hypotension in this setting is controversial; criteria
include a 20% reduction in mean arterial pressure from baseline or a systolic blood
pressure < 100 mm Hg. Hypotension is the consequence of sympathetic blockade
compounded by obstructed venous return from uterine compression of inferior
vena cava and adjacent large veins along with dilatation of vascular beds. A
secondary mechanism may be the decreased maternal endogenous
catecholamines following pain relief. This decrease in blood pressure could be
severe enough to require treatment in one third of patients needing epidural
analgesia.
• Central nervous system toxicity may include dizziness, tinnitus, metallic taste,
numbness of tongue and mouth, slurred speech, bizarre behavior, muscle
fasciculation and excitation, convulsion, or loss of consciousness.
• Postdural puncture headache (PDPH) most likely results from cerebral
vasodilatation or from the traction of cranial structures due to leakage of
cerebrospinal fluid from the site of dural puncture. It occurs with similar frequency
with each method of analgesia (spinal block, 1.5-3%; epidural block, 2%; combined
spinal/epidural [CSE], 1-2.8%).
• Pruritus is a commonly seen with regional opioid administration. It is more likely
to occur with spinal or CSE block (41-85%) than with epidural block alone (1.3-
26%).The etiology appears to be modulation of nociceptive reception, not
histamine release.
• Nausea and vomiting occur commonly in laboring patients as an
accompaniment of visceral pain. Neuroaxial analgesia block
effectively diminishes or eliminates this visceral pain but can also
precipitate nausea and vomiting. The mechanism is a decrease in
blood pressure affecting the area postrema in the medulla or the
cephalad spread of opioids to chemoreceptor trigger zone.
• The associations between back pain and epidural analgesia are
unclear. Chronic back pain has been shown to be associated with
epidural analgesia in retrospective studies. On the contrary,
prospective cohort studies and one small, randomized controlled
trial have found no significant association.
• Local tenderness at the site of epidural or spinal placement and
transient backache are relatively common, particularly if placement
of the block was difficult. This usually clears within several days to 3
weeks and may be related to superficial irritation of the skin or
periosteal irritation or damage.
• Postpartum backache may also be related to hormonal changes,
softening of maternal ligaments, and mechanical changes (eg,
exaggerated lumber lordosis, maternal weight gain).
• Although short-term back pain is common, it does not appear to be related
to the use of regional analgesia. Similarly, no causal relationship exists
between the use of epidural analgesia and the development of long-term
postpartum backache.
• Labor is slightly prolonged with epidural analgesia. The first stage is
prolonged by nearly 30 minutes, and the second stage by 15 minutes.
• The prolongation of the second stage of labor increases the need for
instrumental delivery. However, the reason for this increase with epidural
remains unexplained. The most likely explanations include motor blockade
preventing the mother from pushing, a lower threshold for instrumental
delivery, and an association of higher frequency of persistent
occipitoposterior presentation. The rate of cesarean delivery remains
unchanged.
• Use of oxytocin during labor is increased in the presence of epidural block.
• Fetal bradycardia occurs in 8% of cases. Fetal bradycardia after induction
of regional analgesia may result from decreased cardiac output, decreased
uterine perfusion, or uterine tetany caused by maternal hypotension
• Fever, in association with epidurals, is seen more often in
nulliparous women (19% of nulliparous women, 1% of multiparous
women). Some authors attribute it to placental infection, whereas
others believe it to be noninfectious.
• Breastfeeding success does not depend on the use of regional
analgesia.
• Respiratory depression is a serious adverse effect that can occur
with spinal or epidural analgesia.
• A relationship has been suggested between epidural morphine and
herpes labialis outbreak. Whether reactivation of herpes labialis
follows spinal analgesia is not known.
• Urinary retention during labor is not uncommon, but it appears to
be more likely with regional analgesia. Patients in labor and
postpartum should be observed for possible bladder distension,
particularly when associated with suprapubic pain during uterine
contraction. Urinary retention during labor is treated with
catheterization; intravenous administration of naloxone 400-800
mcg may be necessary.
• Inadequate or failed block happens more often with epidural than spinal
block. The failure rate is as high as 2-5%. In 10-15% of cases, the pain
relief is incomplete. The high failure rate may be related to the
inexperience of practitioners or rapid progression of labor. When the
correct placement of an epidural catheter is in doubt, inject 10-15 mL of
more concentrated local anesthetic (eg, lidocaine 1.5%) in divided doses
to verify placement. If this does not promptly provide significant
analgesia, the epidural catheter should be replaced without prolonged
attempts to verify placement.
• A unilateral epidural block is attributed to obstruction in epidural space,
anatomical causes, patient position (prolonged time on one side), or
excessive catheter length in epidural space. Withdrawal of the catheter by
0.5-2 cm and injection of a larger volume of dilute local anesthetic usually
solves this problem. If these steps do not resolve the problem, replace the
catheter.
• If the patient feels pain because of a change in the nature of her labor
while the catheter is still in place, evaluate the progress of labor and
check for bladder distension. To increase analgesia, the volume or
concentration of the local anesthetic can be increased or an opioid can be
added to the solution. Before adding an opioid, ensure that the catheter
was properly placed and has not been dislodged. Do not add an opioid to
avoid having to replace a misplaced catheter.
• Dense or prolonged epidural block can occur rarely after long
continuous infusions or repeated bolus dosing. The increasing use
of dilute local anesthetics has decreased the incidence of prolonged
or dense block. The resulting significant motor blockade can be
bothersome to the patient and the nursing staff. This may also
make the voluntary maternal expulsive efforts more difficult during
the second stage of labor and lead to prolonged epidural blocks in
the postpartum period, particularly if epinephrine is added to the
anesthetic solution.
• Dense epidural block can be managed by decreasing the epidural
infusion rate or by decreasing the concentration of local anesthetic.
If the block is still bothersome, discontinuing the infusion for 30
minutes may be helpful, followed by restarting the infusion with
more dilute local anesthetic solutions.
• The differential diagnosis includes epidural hematoma. A block that
is unilateral, is not associated with backache, or slowly regresses
and does not progress, would argue against an epidural hematoma.
• High spinal block
• Chemical meningitis or epidural abscess or hematoma
 General Anesthesia in Obstetrics
•General anesthesia can be defined as state of
total loss of sensory perception and include
loss of consciousness and involves systemic
medication and endotracheal intubation.

•The patient is sedated, using either

intravenous medications or gaseous
substances, and muscles paralyzed, requiring
control of breathing by mechanical ventilation.
The General anesthesia comprises three types of
actions on the body:

1. Narcosis by inhaled anesthetic agent (N2O or halogenated

agents or iv (ketamine, barbiturates);

2. The disappearance of pain by analgesia (fentanyl)

3. The administration of a paralytic for the muscle relaxation this

allows the intervention to take place with out difficulties
• General anesthesia is rarely used for delivery, as the mother’s
active presence is essential for a birth without complications to
the fetus.
• However, there are still situations where the physician is
forced to use general anesthesia for childbirth. These as
follows:

1. In emergency C/S when the rapid loss of consciousness and

sensitivity is necessary, insufficient time for regional block.

2. in cases where an epidural anesthesia or the spinal block

cannot be used. Coagulopathy, infections,hypovolemia

3. when the mother cannot tolerate a local anesthetic

4. patient prefer to be “put to sleep”

5. insufficient time for insertion of block

 For Cesarean section delivery
• GA for C/S delivery should cause the mother to be unconscious, feel
no pain and have no unpleasant memories of procedure; the fetus
should not be jeopardized, with minimal depression and intact reflex
irritability.
• A rapid sequence technique is used with cricoids pressure to prevent
aspiration, with recognition that the risks for the term obstetric
patient include:

1. Full stomach (aspiration)

2. Difficulty with laryngoscopy and intubation

3. Rapid desaturation if intubation is unsuccessful

 Anesthesia for Emergency C/S surgery entails
• Placement of ET with inflated cuff to protect the patient from
aspiration of gastric contents into the lung after administration of
adequate barbiturate and a muscle relaxant .

• Several safety measures must be taken:

• Give 30ml of non particulate antacid(sodium citrate)within 15 mins of

induction.
• Accomplished denitrogenation with 100% oxygen by tight-fitting mask
• Inject thiopental 2.5 mg/kg intravenously
• Apply cricoids pressure
• Give succinylcholine 100-120 mg IV
• Intubate the trachea and inflate the cuff
• Give 6-8 deep breaths of 100% oxygen
• Continue to administer nitrous oxide 50 % with oxygen50%,0.5 % halothane
or isoflurane, and maintain relaxation with vecuronium or atracurium.
• Supplement with short acting narcotics and midazolam after the baby is
delivered.
• Wedge should be placed under the patient right hip to prevent vena cava
occlusion from gravid uterus.

• For problems such as midforceps delivery and trapped head then a

regional block is required.

• GA will usually be preferred for emergency C/S following uterine rupture,

antepartum haemorrhage, placental abruption, acute fetal distress cord
prolapse.

• GA may also be requested in the presence of intra-uterine fetal death.

While lesser degrees of placenta praevia can be satisfactorily managed
under regional block.

• Many anesthetists fear the combination of massive maternal

haemorrhage and impairment of cardiovascular reflexes in an awake
patient.

• GA may also be administered for removal of a cervical suture prior to

labour, manual removal of the placenta or products of conception,
treatment of an acute inversion of the uterus and repair of a third degree
tear.
 Complications GA in Obs pt.
• Anesthetic complications are direct injury to the mother/fetus or
toxicity of the GA agent.

• The major concerns of use of GA with Obs pt. are difficulty in

airway management (failed intubation), with anoxia and acid
aspiration leading to materal mortality.

• The GA has more disadvantages than the local anesthesia because

it affects the nervous system of both mother and child.

• Some studies indicate that the percentage of women who died at

birth due to the GA is at least, double, than that caused by the
local anesthesia.
• However with GA there are advantage of rapid induction, less
hypotension, cardiovascular stability .

• In the general anesthesia, the mother will sleep throughout the

intervention and in turn, the baby will be sleepy.

• This risk associated with obstetric general anesthesia has led to

regional techniques being used wherever possible.
 Failed intubation:
• Obs pt. have anesthetic challenges because of a 4 to 5 times higher
frequency of intubation problem and faster development of hypoxia
are the main cause of mortality.

• Change in characteristic of pregant women and comorbidites.

• These factors have significantly contributed to a rising CS rate and

may also affect the risk of difficult/failed intubation.

• Failure of anticipated ease or difficulty of intubation e.g emergency

C/S inadequate airway assessment

• Failure of availability of equipments for emergency airway

management.
 Pulmonary aspiration of the gastric contents:

• aspiration of gastric contents is still a leading cause of maternal

anesthetic death, accounting for 33% of the fatality.

• The high risk of aspiration in obstetric patients due to

physiological changes (↓ gastric emptying, ↑ gastric volume,
↓pH and ↓ gastroesophgeal sphincter tone), obesity and labour-
induced nausea and vomiting.

• A reduced level of consciousness can lead to an unprotected

airway. If the patient vomits they can aspirate the vomitus
contents into their lungs. This can result in lung inflammation
leading to a aspiration pneumonia.
• The risk of aspiration pneumonitis and aspiration
pneumonia is reduced by fasting and cricoid cartilage
pressure .

• Other methods of reducing aspiration pneumonitis are

the use of metoclopramide to enhance gastric emptying
and ranitidine or proton pump inhibitors to ↑the pH of
gastric content.
 Other complications
• Sore throat and laryngeal damage
• Pain
• Anaphylaxsis-depends on severity
• Nausea and vomiting - up to 30% of of rxn. preop assessment is needed
patients & cause should be investigated

• Respiratory depression • Embolism-common during

• Hypoxic brain damage
• Peripheral nerve damage-nerve
compression from exaggerated
positing for prolonged periods
neurosurgical procedures or pelvic
operations. Prophylaxis of
thromboembolism begins
preoperatively with low molecular
weight heparin (LMWH).
• Damage to teeth-check teeth in
preoperative assessment, upper
left incisor most commonly affected
 Fetal Risk

• For the child, the biggest problem that occurs in the general
anesthesia is the poor blood irrigation.

• To prevent the fetus from being sedated because of the general

anesthesia of their mothers,

• the anesthesia is done in the last minute and the babies are
removed quickly so that anesthesia does not have time to get into
their blood.
 Fetal Risks
• Thiopental- no increase in congenital anomalies

• Ketamine- no risk

• N2O-growth retardation and malformation, exposure to high

doses

• Halothane-exposure to increase doses is associated with

musculosketal birth defects.

• Enflurane-limb and abdominal wall defects and also increase

frequency with cleft plate.

• Isoflurane-increase incidence of cleft palate, skeletal variation

and growth retardation.
 Prevention of pulmonary aspiration in obstetric
patients:

• Recognizing the risk of aspiration.

• Avoid GA use

• If GA is unavoidable, the following preventive strategies may be

adopted:
 If GA is unavoidable, the following
preventive strategies may be adopted:
• Position during induction  • Fasting order:

• Prevention of muscle • Prokinetics and

fasciculation anticholinergics:

• Prevention of difficult • Antacid prophylaxis:

airway complications:
  • Awareness:  
• Awake extubation:
• Way forward:
Equipment for airway management in
obstetrics
Routine
• Laryngoscope, multiple
blades (Mac 3,4, Miller 2,3)
• Endotracheal tube (5.0-7.0)
• Oral airways (80, 90 100
mm)
• Nasal airway (7,8,9,)
• Laryngeal masks (size 3 and
4)
• Combitube, Stylets and
bougie
Emergency
• Tube exchanger
• Cricothyrotomy kit
• Transtracheal jet ventilation
equipment
• Light wand, retrograde
intubation equipment
• Anticipated difficult: non
emergency airway
• Fiberoptic laryngoscope and
accessory equipment/
medication
• Fixed fiberoptic blades
(Bullard, Wu scope, Upsher)
Anaesthesia for caesarean
section
With all caesarean sections, it is vital that the
obstetrician clearly communicates the degree of urgency
to all staff.
A suggested classification is:
Immediate: There is immediate threat to the life of
woman or fetus.
Urgent: Maternal or fetal compromise that is not
immediately lifethreatening.
Early: No maternal or fetal compromise, but needs early
delivery.
Elective: Delivery timed to suit woman and staff.
 Regional Anaesthesia
• Regional anaesthesia for caesarean section
was initially driven by maternal preference.
However, regional anaesthesia is also more
than 16 times safer than general anaesthesia.
 Technique
• Three techniques are available-
(1)Epidural
(2)Spinal
(3)combined spinal epidural.
Epidural is most commonly used for women who already
have epidural analgesia in labour.
Spinal is the most popular technique for elective
caesarean section, although in some centres combined
spinal/epidurals are preferred.
a careful history and appropriate examination should be
performed. This should include checking:
• Blood group and antibody screen. Routine cross-
matching of blood is not required unless haemorrhage
is expected or if antibodies that interfere with cross-
matching are present.
• Ultrasound reports to establish the position of the
placenta. A low-lying anterior placenta puts a
woman at risk of major haemorrhage, particularly if
associated with a scar from a previous caesarean
section.
• Fetal and maternal status
 Advantages
• Advantages of regional anaesthesia include:
(1)Both mother and partner can be present at
delivery.
(2)Improved safety for mother with minimal risk
of aspiration and lower risk of anaphylaxis.
(3)The neonate is more alert, promoting early
bonding and breastfeeding.
(4)Fewer drugs are administered, with less
‘hangover’ than after general anaesthesia.
(5)Better postoperative analgesia and earlier
mobilization.
 Epidural anaesthesia for caesarean
section
• Indications for caesarean section under
epidural anaesthesia:
Women who already have epidural analgesia
established for labour.
Severe pre-eclampsia.
Specific maternal disease (e.g. cardiac disease)
where rapid changes in systemic vascular
resistance might be problematic.
 Technique
• History/examination/explanation and consent.
• Ensure that antacid prophylaxis has been given.
• Establish 16G or larger IV access. Give 10–15 ml/kg crystalloid preload.
• Insert an epidural catheter at the L2/3 or L3/4 vertebral interspace.
• Test dose then incrementally top up the epidural with local anaesthetic
and opioid:
– 5–8 ml boluses of 2% lidocaine (lignocaine) with 1:200 000 adrenaline
every 2–3 min up to a maximum of 20 ml (mix 19 ml 2% lidocaine
(lignocaine) with 1 ml 1:10 000 adrenaline rather than using a preparatory
mixture which contains preservative and has a lower pH and therefore
slows onset of the block) or
– 5 ml 0.5% bupivacaine or levobupivacaine or ropivacaine every 4–5 min up
to a maximum of 2 mg/kg in any 4 h period. (the single enantiomer local
anaesthetics may offer some safety advantage; however, lidocaine
(lignocaine) is still safer than both ropivacaine and levobupivacaine).
• Opioid (e.g. 100 µg fentanyl or 2.5 mg diamorphine)
improves the quality of the analgesia and a lower level of
block may be effective if opioid has been given.
• Establish an S4 to T4 block (nipple level) measured by light
touch. Always check the sacral dermatomes, as epidural
local anaesthetic occasionally does not spread caudally.
Anaesthesia to light touch is more reliable at predicting
adequacy of

• Position the patient in the supine position with a left

lateral tilt or wedge. Give supplemental oxygen by
facemask. (This is very important in obese patients who
may become hypoxic when supine, and may benefit a
compromised fetus).
• Treat hypotension with:
– fluid
– 6 mg ephedrine IV bolus (if tachycardia must be avoided
then 50 µg phenylephrine may be used, but expect a reflex
bradycardia)
– increasing the left uterine displacement.
• At delivery give 5–10 IU syntocinon IV bolus. If
tachycardia must be avoided then a slow IV infusion of
30–50 IU syntocinon in 500 ml crystalloid is acceptable.
• At the end of the procedure give an NSAID unless
contraindicated (100 mg diclofenac PR).
 Spinal anaesthesia for caesarean
section
• Spinal anaesthesia is the most commonly used
technique for elective caesarean sections. It is
rapid in onset, produces a dense block, and
with intrathecal opioids can produce long-
acting postoperative analgesia. However,
hypotension is much more common than with
epidural anaesthesia.
 Technique
• History/examination/explanation and consent.
• Ensure that antacid prophylaxis has been given.
• Establish 16G or larger IV access. Give 10–15 ml/kg
crystalloid preload.
• Perform spinal anaesthetic at L3/4 interspace using a 25G
or smaller pencilpoint needle. With the orifice pointing
cephalad inject the anaesthetic solution (e.g. 2.5 ml 0.5%
hyperbaric bupivacaine with 250 µg diamorphine, 15 µg
fentanyl, or 100 µg morphine.
• Use of morphine has little intra-operative benefit but
provides prolonged postoperative analgesia. However, it
carries a higher incidence of postoperative nausea and
vomiting, plus a theoretically increased risk of respiratory
depression.)
• Continue as for epidural anaesthesia for caesarean
section.
• Rapid onset of block may be associated with
fetal acidaemia. Slowing the speed of onset
may be desirable for non-urgent caesarean
section. This can be achieved using the
‘Oxford position’ and hyperbaric local
anaesthetic.
 Combined spinal/epidural anaesthesia
for caesarean section
Indications include:
• Prolonged surgery.
• The epidural catheter may be left in situ and
used for postoperative analgesia.
• When limiting the speed of onset of block is
particularly important. A small intrathecal dose
of local anaesthetic can then be supplemented
through the epidural catheter as required.
 Technique
History/examination/explanation and consent.
Ensure that antacid prophylaxis has been given.
Establish a 16G or larger IV access. Give 10–15
ml/kg crystalloid preload.
• The intrathecal injection may be performed by
passing the spinal needle through the epidural
needle (the ‘needle-through-needle’ technique)
or by performing the intrathecal injection
completely separately from the epidural
placement either in the same or a different
interspace.
• The needle-throughneedle technique is
associated with an increased incidence of
failure to locate CSF with the spinal needle, but
only involves one injection.
• With either technique, beware of performing
the spinal injection above L3/4, as spinal cord
damage has been reported.
Complications of Regional Anaesthesia
• Anesthesia related neurologic deficits
• Serious neurological complications related to
regional anesthesia are fortunately very rare.
Neurological complications may be due to
direct nerve trauma, severe hypotension,
cardiac arrest, equipment problems, adverse
drug effect, administration of the wrong drug
and wrong site of administration.
• Direct trauma to nervous tissue may occur at
the level of the spinal cord, nerve root, or
peripheral nerve. Two thirds of anesthesia
related neurological complications are
associated with either paresthesia (direct
nerve trauma) or pain during injection
(intraneuronal location)
• Spinal needles may touch nerve roots, or directly
injure the spinal cord. If the patient reports
localized pain with insertion of an epidural or
spinal needle or catheter, stop immediately!
• Anatomic variation may alter landmarks and
place nervous tissue at risk for injury. The spinal
cord usually terminates at the 1st lumbar
vertebrae (60%) but may go as low as the L2-3
space (10%). In addition, the superior iliac crest is
usually at the L4 spinous process or L4-5
interspace (79%), however, it may be as high as
the L3-4 interspace (4%)
• Prolonged administration of highlyprotein-
bound drugs (e.g., bupivacaine) may lead to
substantial fetal accumulation of the drugs.
Neonatal depression
• It has been suggested that bupivacaine may
be implicated as a possible cause of neonatal
jaundice because its high affinity for fetal
erythrocyte membranes resulting in a decrease
in filterability and deformability renders
subjects more prone to hemolysis
• Hypotension-greater hemodynamic stability may
be observed with epidural anesthesia

• Maternal prehydration with 15 mL/kg of lactated

Ringer’s solution before initiation of regional
anesthesia and avoidance of aortocaval
compression may decrease the incidence of
hypotension.
• If hypotension does occur despite prehydration,
therapeutic measures should include increasing
displacement of the uterus, rapid infusion of IV
fluids, titration of IV ephedrine (5–10 mg), and
oxygen administration.
• Systemic Toxicity of Local
AnestheticsResuscitation equipment should
always be available life-threatening
convulsions and, more rarely, cardiovascular
collapse may occur.
• Postdural Puncture Headache
 Contraindications
• Regional anesthesia is contraindicated in the
presence of actual or anticipated serious
maternal hemorrhage, refractory maternal
hypotension, coagulopathy, untreated
bacteremia, raised intracranial pressure, skin or
soft tissue infection at the site of the epidural
or spinal placement, and anticoagulant therapy.
• Also if the patient refuses or there is lack of
experience.
 Paracervical Block

• Although paracervical block effectively

relieves pain during the first stage of labor, it
is now rarely used in the United States
because of its association with a high
incidence of fetal asphyxia and poor neonatal
outcome, particularly with the use of
bupivacaine. This may be related to uterine
artery constriction or increased uterine tone.
 Paravertebral Lumbar
Sympathetic Block
• Paravertebral lumbar sympathetic block is a
reasonable alternative when contraindications
exist to central neuraxial techniques. Lumbar
sympathetic block interrupts the painful
transmission of cervical and uterine impulses
during the first stage of labor. Although there is
less risk of fetal bradycardia with lumbar
sympathetic block comparedwith paracervical
blockade, technical difficulties associated with
the performance of the block and risks of
intravascular injection have hampered its
routine use. Hypotension may also occur with
lumbar sympathetic blocks.
 Pudendal Nerve Block

• The pudendal nerves are derived from the

lower sacral nerve roots (S2-4) and supply the
vaginal vault, perineum, rectum, and sections
of the bladder. The nerves are easily blocked
transvaginally where they loop around the
ischial spines. Local anesthetic, 10 mL,
deposited behind each sacrospinous ligament
can provide adequate anesthesia for outlet
forceps delivery and episiotomy repair.
• Lucas DN, Yentis SM et al. (2000). Urgency of
7

caesarean section: a new classification.

Journal of the Royal Society of Medicine, 93,
346–50.
• 8 Hawkins JL, Koonin LM et al. (1997).
Anesthesia-related deaths during obstetric
delivery in the United States, 1979–1990.
Anesthesiology, 86, 277–84. Ovid Full Text
Resuscitation of Pregnant
Mother
 Interventions to Prevent Arrest
• Place the patient in the full left-lateral position to
relieve possible compression of the inferior vena
cava.
• Give 100% oxygen.
• Establish intravenous (IV) access above the
diaphragm.
• Assess for hypotension; maternal hypotension
that warrants therapy has been defined as a
systolic blood pressure <100 mm Hg or <80% of
baseline.
• The primary goal in the initial management of
the injured pregnant woman is the
stabilization of the mother.
• Maternal resuscitation is the most effective
method of fetal resuscitation.
 Physiological changes in late pregnancy
affecting cardiopulmonary resuscitation
Respiratory
• Increased ventilation
• Increased oxygen demand
• Reduced chest compliance
• Reduced functional residual capacity
Cardiovascular
• Incompetent gastroesophageal (cardiac)
sphincter
• Increased intragastric pressure
• Increased risk of regurgitation
 Basic Life Support
Airway
• A clear airway must be quickly established with the
head tilt-jaw thrust or head tilt-chin lift maneuver
and then maintained.
• Finger sweep, at the same time badly fitting
dentures and other foreign bodies should be
removed from the mouth, and an airway should be
inserted.
• Suction should be used to aspirate vomit.
• These procedures should be performed with the
patient inclined laterally or supine and the uterus
displaced.
 Patient Positioning
• Left uterine displacement with two handed
technique
• Left uterine displacement using one handed
technique.
• Patient in a 30° left-lateral tilt using a firm
wedge to support pelvis and thorax.
 Breathing
• If the patient is not breathing adequately, intermittent positive
pressure ventilation should be started once the airway has
been cleared; mouth to mouth, mouth to nose, or mouth to
airway ventilation should be carried out until a self inflating bag
and mask are available.
• Ventilation should then be continued with 100% oxygen and a
reservoir bag.
• Because of the increased risk of regurgitation and pulmonary
aspiration of gastric contents in late pregnancy, cricoid pressure
should be applied until the airway has been protected by a
cuffed tracheal tube.

• NOTE: Ventilation is made more difficult by the increased

oxygen requirements and reduced chest compliance in
pregnancy. The reduced compliance is due to rib flaring and
splinting of the diaphragm by the abdominal contents.
Observing the rise and fall of the chest in pregnant patients is
also more difficult.
 Circulation
• Circulatory arrest is diagnosed by the absence of a
palpable pulse in a large artery (carotid or femoral).
• In hypovolaemia establish iv access and give fluids.
• Chest compressions are given at the standard rate and
ratio of 15:2.
• Chest compression on a pregnant woman is made
difficult by flared ribs, raised diaphragm, obesity, and
breast hypertrophy.
• Because the diaphragm is pushed upwards by the
abdominal contents, the hand position for chest
compressions should similarly be moved up the
sternum, although currently no guidelines suggest
exactly how far.
• In the supine position an additional factor is
compression of the inferior vena cava by the gravid
uterus, which impairs venous return and reduces
cardiac output; all attempts at resuscitation will be
futile unless the compression is relieved.

• This is achieved either by placing the patient in an

inclined lateral position by using a wedge or by
displacing the uterus manually.

• Raising the patient's legs will improve venous return.

 Advance Life Support
Intubation
• Tracheal intubation should be carried out as soon as
facilities and skill are available.
• Difficulty in tracheal intubation is more common in
pregnant women, and specialised equipment for
advanced airway management may be required.
• A short obese neck and full breasts due to pregnancy
may make it difficult to insert the laryngoscope into
the mouth.
• The use of a short handled laryngoscope or one with
its blade mounted at more than 90° (polio or
adjustable blade) or demounting the blade from the
handle during insertion into the mouth may help.
• Mouth to mouth or bag and mask ventilation is best done
without pillows under the head and with the head and neck
fully extended. The position for intubation, however,
requires at least one pillow to flex the neck and extend the
head. Any pillow removed to facilitate initial ventilation
must, therefore, be kept at hand for intubation.

• In the event of failure to intubate the trachea or ventilate

the patient's lungs with a bag and mask, insertion of a
laryngeal mask airway should be attempted. Cricoid
pressure must be temporarily removed in order to place
the laryngeal mask airway successfully. Once the airway is
in place, cricoid pressure should be reapplied.
 Defibrillation and Drugs
• Identify the cardiac arrest rhythm which can
be either shockable (ventricular fibrillation,
VT) or non shockable (asystole, pulseless
electrical activity)
• Adrenaline cause vasoconstriction thus,
increases total peripheral resistance. Its given
1mg intravenously every 3 minutes
• Increasingly, magnesium sulphate is used to
treat and prevent eclampsia. If a high serum
magnesium concentration has contributed to
the cardiac arrest, consider giving calcium
chloride. Tachyarrhythmias due to toxicity of the
anaesthetic drug bupivacaine are probably best
treated by electrical cardioversion or with
bretylium rather than lidocaine (lignocaine).
 Caesarean Section
• Many successful resuscitations have occurred
after prompt surgical intervention.
• The probable mechanism for the favourable
outcome is that occlusion of the inferior vena
cava is relieved completely by emptying the
uterus, whereas it is only partially relieved by
manual uterine displacement or an inclined
position.
• Delivery also improves thoracic compliance,
which will improve the efficacy of chest
compressions and the ability to ventilate the
lungs.
• After cardiac arrest, non-pregnant adults suffer
irreversible brain damage from anoxia within three
to four minutes, but pregnant women become
hypoxic more quickly.
• If maternal cardiac arrest occurs in the labour ward,
operating theatre, or accident and emergency
department, and basic and advanced life support
are not successful within five minutes, the uterus
should be emptied by surgical intervention.
• Given the time taken to prepare theatre packs, this
procedure is probably best carried out with just a
scalpel.
• Time passes very quickly in such a high pressure
situation, and it is advisable to practice this
scenario, particularly in the accident and emergency
department.
Obstetric Anesthetic Mortality
• Anesthetic-related maternal mortality decreased
nearly 60% when data from 1979–1990 were
compared with data from 1991–2002.
• The case fatality rate with general anesthesia was
16.7 times greater than that with regional
anesthesia.
• Although case-fatality rates for general
anesthesia are falling, rates for regional
anesthesia are rising.
• Regional anesthesia is now more commonly
performed for cesarean delivery.
• General anesthetic deaths for cesarean has
risen from 20 deaths in the 1980s to 32.3
deaths.
• Simultaneously case fatality rates for regional
anesthesia decreased from 8.6 to 1.9 per
million regional anesthetic.
• General anesthesia case fatality rate may have
increased because now, it is reserved for
urgent and critical situations, whereas in the
past it was more commonly used for elective
obstetric delivery.
• Most anesthesia-related deaths were as a result
of cardiac arrest due to hypoxemia when
difficulties securing the airway were
encountered.
• Pregnancy-induced anatomic and physiologic
changes, such as reduced functional residual
capacity, increased oxygen consumption, and
oropharyngeal edema, may expose the patient to
serious risks of desaturation during periods of
apnea and hypoventilation.
 Reference
• http://journals.lww.com/greenjournal/Abstra
ct/2011/01000/Anesthesia_Related_Maternal
_Mortality_in_the.11.aspx
• http://www.bmj.com/content/327/7426/127
7.full
 References
• anesth.utmb.edu/.../Techniques%20of
%20Labor%20Analgesia.ppt
• www.rhodeislandhospital.org/rih/services/.../
obstetricalanesthesia.ppt
• emedicine.medscape.com/article/149337-
overview
• Kaball; Oxford handbook of Anaesthesia