ANESTHESIA AND ANALGESIA

Far Eastern University

Dr. Nicanor Reyes Medical Foundation Department of Obstetrics and Gynecology

MATERNAL RISK FACTORS ANESTHESIA CONSULTATION: 1. Marked Obesity

THAT

SHOULD

PROMPT

2. Severe edema or anatomical abnormalities of face, neck, or spine, including trauma or surgery 3. Abnormal dentition, small mandible, or difficulty opening mouth 4. Extremely short stature , short neck, or arthritis of the neck

5. Goiter
6. Serious maternal medical pulmonary or neurological disease 7. Bleeding disorders 8. Severe preeclampsia 9. Previous history of anesthetic complications problems, such as cardiac,

Goals for Optimizing Obstetrical Anesthesia Services

 Availability of a licensed practitioner who is credentialed to administer an appropriate anesthetic whenever necessary and to maintain support of vital functions in an obstetrical emergency Availability of anesthesia personnel to permit the start of a cesarean delivery within 30 minutes of the decision to perform the procedure Anesthesia personnel immediately available to perform an emergency cesarean delivery during the active labor of a woman attempting vaginal birth after cesarean Appointment of a qualified anesthesiologist to be responsible for all anesthetics administered

Goals for Optimizing Obstetrical Anesthesia Services

Goals for Optimizing Obstetrical Anesthesia Services Availability of a qualified physician with obstetrical privileges to perform operative vaginal or cesarean delivery during administration of anesthesia Availability of equipment, facilities, and support personnel equal to that provided in the surgical suite Immediate availability of personnel, other than the surgical team, to assume responsibility for resuscitation of the depressed newborn

ROLE OF AN OBSTETRICIAN

Every obstetrician should be proficient in local and pudendal analgesia that may be administered in appropriately selected circumstances General anesthesia should be administered only by those with special training

Principles of Pain Relief

Labor pain is a highly individual reflection of variable stimuli. These stimuli are modified by emotional, motivational, cognitive, social, and cultural circumstances Choice among a variety of methods and individualization of pain relief is desirable

Nonpharmacological Methods of Pain Control

NONPHARMACOLOGICAL METHODS OF PAIN CONTROL

1.LAMAZE Pain often can be lessened by teaching pregnant women relaxed breathing and their labor partners psychological support techniques. The presence of a supportive spouse or other family member, of conscientious labor attendants, and of a considerate obstetrician who instills confidence, have all been found to be of considerable benefit. 2. CLINICAL HYPNOSIS power of the mind to heal the body; increases of beta endorphins in the peripheral blood 3. ACUPUNCTURE

PARENTERAL AGENTS

PARENTERAL AGENTS
1. Meperidine and Promethazine

Meperidine 50-100mg and Promethazine 25 mg administered intramuscularly at intervals of 2 to 4 hours

More rapid effect if given intravenously in doses of 25 to 50mg every 1 to 2 hours

Meperidine - readily crosses the placenta

Half-life: 13 hours or longer in the newborn

PARENTERAL AGENTS
2. Butorphanol (Stadol) Synthetic narcotic 1-2mg doses Major side effects: somnolence, dizziness and dysphoria Neonatal respiratory depression is less than with Meperidine Antagonizes the narcotic effects of Meperidine 3. Fentanyl Short-acting, very potent synthetic opioid 50-100 g intravenously every hour Main disadvantage: short duration of action

EFFICACY AND SAFETY OF PARENTERAL AGENTS

1. Meperidine is the most common opioid used worldwide for pain relief in labor.
2. There is no convincing evidence demonstrating that alternative opioids are better. 3. There is no evidence that parenteral opioids influence the length of labor or need for obstetrical intervention.

4. Epidural analgesia provides superior pain relief.

Meperidine or other narcotics cause newborn respiratory depression

NARCOTIC ANTAGONISTS
Naloxone Capable of reversing respiratory depression induced by opioid narcotics Withdrawal symptoms may be precipitated in recipients who are physically dependent on narcotics Contraindicated in newborn of narcotic-addicted mother

NITROUS OXIDE
Self-administered mixture of 50% nitrous oxide and oxygen provides satisfactory analgesia during labor

REGIONAL ANALGESIA

SENSORY INNERVATION OF THE GENITAL TRACT

Uterine Innervation

Pain during 1st stage of labor generated largely from the uterus
Visceral sensory fibers from the uterus, cervix, and upper vagina traverse through the Frankenhuser ganglion, which lies just lateral to the cervix, into the pelvic plexus, and then to the middle and superior internal iliac plexuses.

Early in labor pain of uterine contractions transmitted through the T11 and T12 nerves
Motor pathways leave the spinal cord at the level of the T7 and T8 vertebrae

Motor: T7 & T8

Early labor: T11 T12

Lower Genital Tract Innervation

Pain with vaginal delivery arises from stimuli from the lower genital tract. Transmitted primarily through the pudendal nerve Pudendal nerve sensory nerve fibers derived from the ventral branches of the S2 through S4 nerves Passes beneath the posterior surface of the sacrospinous ligament just as the ligament

ANESTHETIC AGENTS
(Table 19-3. Some Local Anesthetic Agents used in Obstetrics)

Central Nervous System Toxicity

Early symptoms are those of stimulation but as serum levels increase depression follows Light-headedness, dizziness, tinnitus, metallic taste and numbness of the tongue and mouth

Bizarre behavior, slurred speech, muscle fasciculation and excitation and generalized convulsions, followed by loss of consciousness

Cardiovascular Toxicity Generally develop later than those from cerebral toxicity Hypertension and tachycardia, which is soon followed by hypotension and cardiac arrhythmias

PUDENDAL BLOCK
Relatively safe and simple
A tubular introducer that allows 1.0 to 1.5 cm of a 15-cm 22-gauge needle is used to guide the needle into position over the pudendal nerve

Complications: may cause serious systemic toxicity, hematoma formation from perforation of a blood vessel

PARACERVICAL BLOCK

Provides satisfactory pain relief during the first stage of labor Lidocaine or Chloroprocaine 5-10mL is injected into the cervix laterally at 3 and 9 oclock Complication: fetal bradycardia usually develops within 10 minutes and may last up to 30 minutes

SPINAL (SUBARACHNOID) BLOCK

Advantages: short procedure time, rapid onset of block, high success rate Vaginal Delivery Popular form of analgesia for forceps or vacuum delivery Should extend to the T10 dermatome Lidocaine or Bupivacaine Cesarean Delivery Level of sensory blockade extending to the T4 dermatome 10-12 mg of hyperbaric bupivacaine or 50-75mg of hyperbaric Lidocaine

COMPLICATIONS OF SPINAL (SUBARACHNOID) BLOCK

Hypotension High spinal blockade Spinal (Postural puncture) headache Convulsions Bladder dysfunction Oxytocics and hypertension Arachnoiditis and meningitis

CONTRAINDICATIONS TO SPINAL ANESTHESIA

ABSOLUTE CONTRAINDICATIONS Refractory maternal hypotension Maternal coagulopathy Treatment with once-daily dose of low-molecularweight heparin within 12 hours Untreated bacteremia Skin infection over site of needle placement Increased intracranial pressure caused by mass lesion

EPIDURAL ANESTHESIA
Continuous Lumbar Epidural Block VAGINAL DELIVERY - Block from T10 to S5 dermatomes CESAREAN DELIVERY - Block extending from the T4 to S1 dermatomes is desired

COMPLICATIONS OF EPIDURAL ANESTHESIA

Total spinal blockade Ineffective analgesia Hypotension Central nervous stimulation Maternal pyrexia Back pain

EPIDURAL ANESTHESIA
Effect on Labor
Prolongs active phase of labor by 1 hour Increases the need for instrumental delivery due to prolonged second-stage labor Fetal Heart Rate associated with improved neonatal acidbase status compared with meperidine Cesarean Delivery Epidural administration of dilute solutions of local anesthetic is less likely to increase cesarean delivery rates than concentrated solutions. Timing of epidural placement women in labor should not be required to reach 4-5cm of cervical dilatation before receiving epidural analgesia

EPIDURAL ANESTHESIA
Safety No maternal deaths Very low incidence of complications

Contraindications

Maternal hemorrhage Infection at or near the sites of puncture Suspicion of neurological disease Anticoagulation women receiving anticoagulation therapy are at increased risk for spinal cord hematoma an compression

EPIDURAL ANESTHESIA

Severe Preeclampsia-Eclampsia Most have come to favor epidural blockade for labor and delivery in women with severe preeclampsia Labor epidural analgesia is to be considered in women with hypertensive disorders, but it is not to be considered as therapy. Provided superior pain relief without significant increase in maternal or neonatal complications

EPIDURAL ANESTHESIA
Epidural Opiate Analgesia Most often given with a local anesthetic agent such as bupivacaine ADVANTAGES Rapid onset of pain relief Decrease in shivering Less dense motor blockade SIDE EFFECTS Pruritus Urinary retention Immediate or delayed respiratory depression

COMBINED TECHNIQUES

SPINAL-EPIDURAL

May provide rapid and effective analgesia for labor as well as for cesarean delivery
Needle-through-needle technique An introducer needle is first placed in the epidural space, then a small-gauge spinal needle is introduced through the epidural needle into the subarachnoid space.

LOCAL INFILTRATION FOR CESAREAN DELIVERY To augment an inadequate or patchy regional block that was given in an emergency 1st - halfway between the costal margin and iliac crest in midaxillary line to block the 10th, 11th, and 12th intercostal nerves. 2nd - along the line of proposed skin incision. 3rd - at the external inguinal blocks the genitofemoral and ilioinguinal nerves.

GENERAL ANESTHESIA
PATIENT PREPARATION ANTACIDS Administered shortly before induction of anesthesia Sodium citrate with citric acid (Bacitra) 30mL given 45 minutes before surgery UTERINE DISPLACEMENT With lateral uterine displacement, the duration of general anesthesia has less effect on neonatal condition than when the woman remains supine.

Severe Preeclampsia-Eclampsia

Most have come to favor epidural blockade for labor and delivery in women with severe preeclampsia Labor epidural analgesia is to be considered in women with hypertensive disorders, but it is not to be considered as therapy.
Provided superior pain relief without significant increase in maternal or neonatal complications

GENERAL ANESTHESIA

Preoxygenation
Because functional reserve capacity is reduced, pregnant women become hypoxemic more rapidly during periods of apnea than do nonpregnant patients. 100% oxygen via face mask for 2-3 minutes prior to anesthesia induction to replace nitrogen in the lungs with oxygen

INDUCTION OF ANESTHESIA

Thiopental Ease and rapid, with minimal risk of vomiting Poor analgesic agents May cause appreciable newborn depression if given alone Ketamine Used to render patient unconscious Given intravenously in low doses of 0.2 to 0.3 mg/kg Not associated with hypotension Usually causes a rise in blood pressure Unpleasant delirium and hallucinations are commonly induced by this agent.

INTUBATION Succinylcholine

Rapid-onset and short-acting muscle relaxant Sellick maneuver Cricoid pressure is used to occlude the esophagus from induction until intubation

FAILED INTUBATION

Although uncommon, failed intubation is a major cause of anesthesia-related maternal mortality.

A history of previous difficulties with intubation as well as a careful assessment of anatomical features of the neck, maxillofacial, pharyngeal, and laryngeal structures may help predict a difficult intubation. Edema of the airway may develop intrapartum and present considerable difficulties.

FAILED INTUBATION
Morbid obesity is also a major risk factor for failed or difficult intubation. An important principle is to start the operative procedure only after it has been ascertained that tracheal intubation has been successful and that adequate ventilation can be accomplished. Following failed intubation, the woman is ventilated by mask and cricoid pressure is applied to reduce the chance of aspiration. Surgery may proceed with mask ventilation or the woman may be allowed to awaken.

GAS ANESTHETICS

GAS ANESTHETICS
Volatile Anesthetics Most commonly used is isoflurane. Potent nonexplosive agent that produce remarkable uterine relaxation when given in high, inhaled concentration USES: Internal podalic version of the second twin Breech decomposition Replacement of acutely inverted uterus Occasionally associated with hepatitis and massive hepatic necrosis

GAS ANESTHETICS
Anesthesia Gas Exposure and Pregnancy Outcome All anesthetic agents that depress the maternal central nervous system cross the placenta and depress the fetal central nervous system. Induction-to-delivery time should be minimized

GAS ANESTHETICS

EXTUBATION
The tracheal tube may be safely removed only if the woman is conscious to a degree that enables her to follow commands and is capable of maintaining oxygen saturation with spontaneous respiration. ASPIRATION

Aspiration pneumonitis has been the most common cause of anesthetic deaths in obstetrics.

FASTING
A fasting period of 8 hours or more is preferable for uncomplicated parturients undergoing elective cesarean delivery.

PATHOPHYSIOLOGY

The right mainstem bronchus usually offers the simplest pathway for aspirated material to reach the lung parenchyma, and therefore the right lower lobe is most often involved.
The woman who aspirates may develop evidence of respiratory distress immediately or as long as several hours after aspiration, depending in part on the material aspirated and the severity of the process.

TREATMENT

Respiratory rate and oxygen saturation as measured by pulse oximetry are the most sensitive and earliest indicators of injury. When acute respiratory distress syndrome develops, mechanical ventilation with positive end-expiratory pressure may prove lifesaving.

Types of Analgesic and Sedation

Effects Side Effects

Meperidine 50-100mg Does not lead to Depressant effect in with Promethazine prolongation of labor, the fetus follows peak 25mg IM every 3 to 4 rather an increase in analgesic affect in hours uterine activity mother Butorphanol 1-2mg Compares with 4060mg of Meperidine Less respiratory depression Not given contiguously with Meperidine, antagonizes the narcotic effect of Meperidine

Fentanyl 50-100ug/hr Safe, without effect on active phase of labor Nalbuphine 15-20mg No neonatal

General Anesthesia
Nitrous Oxide
Route of Administration Inhalation Mechanism of Advantages Disadvantages Action Alter the function Low potency, Produces of receptors for therefore must be analgesia and neurotransmitters, combined with altered nonselectively, other agents; consciousness; controlling the Rapid induction and Risk of bone overall state of recovery; marrow consciousness and Good analgesic depression due to response to properties; inhibition of sensory stimuli Does not prolong Methionine labor or interfere synthase with with uterine prolonged contractions administration Same Halogenated Some risk of anaesthetic similar epilepsy-like to halothane; seizures Less metabolism than halothane, therefore less risk of toxicity; Fast induction and recovery than

Enflura ne

Inhalation

Route of Administration

Mechanism of Action Same

Advantages

Disadvantages

Isoflurane

Inhalation

Halothane

Inhalation

Same

Similar to Enflurane, Unconsciousness; but lacks Potential for epileptogenic aspiration in an property; unprotected airway; May precipitate Crosses the placenta myocardial ischaemia produce narcosis in in patients with the fetus; coronary disease Produces uterine relaxation in high doses Widely used agent Potential for aspiration in an unprotected airway; Crosses the placenta produce narcosis in the fetus; Produces uterine relaxation in high doses; Risk of liver damage if used repeatedly

Indication

Pudendal block

Provide analgesia for spontaneous delivery Can be used with epidural analgesia given during labor
Provide good to excellent pain relief during the first stage of labor For forceps and vacuum delivery

Complications and their Precautions Management Intravascular injection may May not provide cause serious toxicity adequate analgesia for characterized other than outlet delivery or when delivery requires extensive manipulation Fetal bradycardia, as a consequence of transplacental transfer of the anesthetic agent Hypotension Total spinal blockage Spinal headache Convulsions Bladder dysfunction Hypotension Urinary retention Cardiorespiratory arrest Maternal pyrexia Back pain Relatively short acting, may have to be repeated during labor Disorder of coagulation and defective hemostasis preclude the use of spinal analgesia Before any injection of the local anesthetic agent, a test dose is given and the women observed for features of toxicity from intravascular injection and signs of spinal blockade form subarachnoid injection

Paracervical block

Spinal (subarachnoid) block Epidural block

Relief of pain of uterine contractions and delivery, vaginal or abdominal