Obstetrical

Anesthesia
Dr Lindsey Patterson

Objectives

Overview of maternal physiology

Analgesia for labor and delivery
Regional anesthesia
Anesthesia concerns in the
parturient
Study MCQs with explanations

Physiological ChangesCVS
Almost all the changes seen are due to high
levels of progesterone and include:

35% Total Blood Volume

heart rate 15 beats/min
40% CO
30% SV
15% SVR
500ml/min blood flow to uterus
venous return from legs
AORTOCAVAL COMPRESSION (mechanical)

Impact of CVS changes

Patients with pre-existing cardiac

disease may decompensate
either during labor or immediately
post delivery. This corresponds to
the time of maximal CO
Approx 400 600ml blood loss
occurs at delivery
Supine hypotensive syndrome

Aortocaval Compression

Physiological Changes
- Resp

oxygen consumption ~ 20%

(100% in labor) due to increased
metabolic rate
minute ventilation ~ 50% (due
to increased tidal volume)
arterial pCO2
FRC causing a decrease in
oxygen reserves

Impact of Resp.
changes

Uptake of inhalational agents is

faster
Decreased FRC and increased
oxygen consumption increase the
risk of hyoxia with apnea
Preoxygenation prior to GA less
effective

Physiological ChangesAirway

Venous engorgement of airway

mucosa
Edema of airway mucosa
Worsening of Mallampati score in
labor

Impact of Airway
Changes

Trauma to upper airway with

suctioning, intubation
Increased incidence of
difficult/failed intubation x10
Require smaller ETT

Physiological ChangesCNS

Decrease in MAC by 25 40%

Decreased dose of Local
Anesthetic requirement for
regional techniques
More rapid onset of neural
blockade

Impact of CNS Changes

Decreased inhalation anesthetic

agent requirements
Decreased dose of local
anesthetic for same effect
Increased risk of local anesthetic
toxicity

Physiological Changes
- GIT

Increased gastric fluid volume

Increased gastric fluid acidity
Decreased competency of lower
esophageal sphincter

Impact of GIT Changes

Increased risk of aspiration

All parturients are a full stomach
Aspiration prophylaxis
recommended for C/S

0.3M Sodium citrate 30 mls po

Ranitidine 50mg iv
Metoclopramide 10mg iv

Analgesia for labor

and delivery

Where is the pain coming from?

Is pain bad in labor?
Analgesic options

Pain of childbirth
Nociceptive
pathways
involved
T10 L1 during
labor
plus
S2-S4 for delivery

Is pain bad in labor?

Psychological stress can cause:
increased levels of catecholamines
hyperventilation
These may result in decreased
uterine blood flow leading to
hypoxia and acidosis in the fetus

Factors affecting pain

perception in labor

Mental preparation
Family support
Medical support
Cultural expectations
Underlying mental status
Parity
Size and presentation of the fetus
Maternal pelvic anatomy
Duration of labor
Medications

Analgesia for labor

and delivery

Non-medication
Inhalational
Parenteral
Regional

Analgesia- Non
medication options

Breathing exercises
Autohypnosis
Acupuncture
White Noise/ Music
Massage/ walking
TENS
Water bath

Inhalation Medications

Nitronox: 50:50 mixture of oxygen and

nitrous oxide
Low dose Isoflurane in oxygen

Advantages: on demand delivery,

relatively safe
Disadvantages: variable efficacy, nausea,
drowsiness, neonatal depression

Parenteral Medications

Narcotics: meperidine, morphine

fentanyl

Advantages: relatively good analgesia

Disadvantages: nausea, vomiting,
sedation, neonatal depression (max. 2
hours after meperidine dose), short
duration of action

Regional techniques

Epidural, spinal, combined spinal-epidural

Advantages: excellent pain control, minimal

impact on progress of labor with low
doses, less drug transfer to fetus,
improved uterine blood flow, decrease in
birth trauma e.g. use of forceps, minimal
neonatal depression
Disadvantages: invasive technique, side
effects (hypotension, headache, itching,
nausea, urinary retention, limited
mobility), nerve damage, infection

Anesthesia in the
parturient

General considerations of the

parturient undergoing surgery
Obstetric surgery

General considerations

Altered physiology as mentioned

Risks to the fetus:
Effect of the disease process/therapies
Possible teratogenicity of anesthetic
agents
Intraoperative effects on
uteroplacental blood flow
Increased risk of preterm labor/ risk of
abortion

Maternal
considerations

Altered physiology
Altered response to anesthesia
Decrease in MAC
Increased sensitivity to neuraxial
agents
Decreased plasma cholinesterase
Decreased protein binding (more free
drug)
Limited drug information in parturients

Fetal Considerations

Teratogenicity:
Limited information due to
impracticality of conducting trials
with sufficient power
Guidelines based on a) effects on
reproduction in animals; b)
epidemiological surveys of OR
personnel; c) studies of pregnancy
outcomes in parturient undergoing
ante partum surgery

Nitrous oxide has been shown to have a

teratogenic effect in rats during the first
trimester
No anesthetic agent is a proven teratogen
in humans
Anesthetic agents deemed safe include:
thiopental,morphine, meperidine,fentanyl,
succinylcholine, NDMRs
Limiting nitrous oxide use but only if
hypotension secondary to volatiles can be
avoided

Anesthetic management in the

parturient should be directed to:

Avoidance of hypoxemia
Avoidance of hypotension
Avoidance of acidosis
Maintain PaCO2 in the normal range
for the parturient
Minimize effects of aortocaval
compression

Anesthesia for
Caesarean Section

Preparation
Preventing complications
Choice of Anesthetic technique
Effects on the fetus

Preparation

Premeds: antacid (sodium citrate)

IV access and fluid bolus within 30
minutes of operating (avoid glucose
containing fluids)
Left lateral tilt with wedge under right
pelvis
Routine Monitors: ECG, NIBP, pulse
oximeter, fetal monitoring
Additional monitors for GAs: ETCO2,
nerve stimulator, temp probe

Preventing
complications

Aspiration prophylaxis
Detailed airway assessment
Fluid resuscitation/left lateral tilt
to prevent hypotension
Safe practice for placement of
neuraxial blocks

Anesthetic techniques

Local infiltration by surgeon

Regional anesthesia: spinal,
epidural, combined spinalepidural
General anesthesia

Local Infiltration

Rarely performed
Patient usually in extremis
Surgery must be done via midline
incision, gentle retraction, no
exteriorization of the uterus
Usually done to supplement a
regional technique if local
anesthetic toxicity not a concern

Regional: Spinal
Anesthesia

Simple to perform
Rapid onset
Single shot technique
Profound neural block
Technique of choice for
uncomplicated elective caesarean
sections and in many emergency
caesarean sections

Spinal Anesthesia

Potential Complications:

Hypotension
Headache (rare ~1:100)
Backache (temporary ~24hrs)
Nausea/vomiting (secondary to BP,
narcotics)
Neurological damage (very rare)
Anaphylaxis (very rare)

Regional: Epidural
Anesthesia

More technically challenging

Slower onset
Used when already placed for
labor analgesia
Useful in parturient where a slow,
controlled onset of block is needed
Allows prolongation of block should
surgery be complicated

Epidural Anesthesia

Potential Complications:

Hypotension
Headache (approx 1:100)
Transient backache ~24hrs
Urinary retention
Unintentional spinal injection
Intravascular injection of local
anesthetic
Neurological damage
Infection

Regional: Combined
spinal-epidural

Used when require the speed and

density of a spinal anesthetic with
the flexibility of prolonging the
block by supplemental increments
of local anesthesia via the
epidural catheter
Complications: as mentioned for
spinals and epidurals

General Anesthesia

Used when
Patient refuses regional technique
Regional technique is
contraindicated
Emergency C/S when there is
inadequate/absent regional
analgesia and to delay will cause
undue risk to the fetus / mother

General Anesthesia

Complications:
Failed intubation
Failed ventilation causing death or
neurological injury
Awareness
Aspiration pneumonia

Anesthesia: Effects on
the fetus

Avoid hypotension, hypoxia, acidosis,

hyperventilation
Limit time between uterine incision and
delivery to less than 3 minutes
Infants exposed to GA have lower Apgar
at one minute but no difference at 5 mins
No significant alteration in
neurobehavioral scores with regional
techniques

MCQ 1. Epidural Anesthesia

in Obstetric Practice. Which
of the following is false.

A. Commonly causes itching

B. Can be used to control blood
pressure in pre-eclampsia
C. Causes uterine relaxation
D. Causes urinary retention
E. Contributes to the effects of
aortocaval compression

MCQ 1. Epidural Anesthesia

in Obstetric Practice

A. Commonly causes itching

B. Can be used to control blood
pressure in pre-eclampsia
C. Causes uterine relaxation
D. Causes urinary retention
E. Contributes to the effects of
aortocaval compression

Itching is one of the most common

side-effects of opioids when delivered
in the epidural space. Their use
allows for a decreased concentration
of local anesthetic whilst maintaining
excellent analgesia. Patients have
better motor function and retain the
ability to push.

MCQ 2. All of the following are

false concerning general
anesthesia in the parturient,
EXCEPT:
A. General anesthesia reduces gastric

pH
B. MAC is decreased
C. It is contra-indicated in patients
with a bleeding diathesis
D. Is a major cause of overall
maternal mortality
E. Succinylcholine crosses the
placenta

MCQ 2. All of the following are

false concerning general
anesthesia in the parturient,
EXCEPT:
A. General anesthesia reduces gastric

pH
B. MAC is decreased
C. It is contra-indicated in patients
with a bleeding diathesis
D. Is a major cause of overall
maternal mortality
E. Succinylcholine crosses the
placenta

General anesthetics have no effect on

gastric pH.
It is the method of choice in patients
with a bleeding diathesis since regional
anesthesia is contra-indicated.
Although of concern to Anesthesiologists
general anesthesia is not a major
cause of maternal mortality.
Succinylcholine is unable to cross the
placenta and effect the fetus.

MCQ 3. The following are all

true concerning the nerve
supply of the uterus , EXCEPT:

A. Sensation from the upper segment

travels with the sympathetic nerves to
T11-T12
B. Sensation from the birth canal is via
the pudendal nerve
C. Lower segment innervation is via S2-4
D. Motor function occurs via sympathetic
and parasympathetic nerves
E. An intact nerve supply is essential to
initiate normal labor

MCQ 3. The following are all

true concerning the nerve
supply of the uterus , EXCEPT:

A. Sensation from the upper segment

travels with the sympathetic nerves to
T11-T12
B. Sensation from the birth canal is via
the pudendal nerve
C. Lower segment innervation is via S2-4
D. Motor function occurs via sympathetic
and parasympathetic nerves
E. An intact nerve supply is essential to
initiate normal labor

Normal labor occurs in patients

with a transected spinal cord.

MCQ 4: Physiological changes

seen in the last trimester
include all EXCEPT

A. Resting PaCO2 is decreased

B. Hematocrit is decreased
C. Blood volume is increased
D. Gastric secretion is increased
E. Total peripheral resistance is
decreased

MCQ 4: Physiological changes

seen in the last trimester
include all EXCEPT

A. Resting PaCO2 is decreased

B. Hematocrit is decreased
C. Blood volume is increased
D. Gastric secretion is increased
E. Total peripheral resistance is
decreased

Gastric acid production does not

increase. There is an increased
risk of aspiration due to delayed
gastric emptying and a decrease
in lower esophageal sphincter
tone.

MCQ 5: All of the following are

suitable for aspiration
prophylaxis prior to caesarean
section,
EXCEPT:
A. Metoclopramide
B. Glycopyrollate
C. Sodium citrate
D. Clear fluids 4 hours pre-op
E. Ranitidine

MCQ 5: All of the following are

suitable for aspiration
prophylaxis prior to caesarean
section,
EXCEPT:
A. Metoclopramide
B. Glycopyrollate
C. Sodium citrate
D. Clear fluids 4 hours pre-op
E. Ranitidine

Metoclopramide acts as a pro-kinetic to

empty the stomach of any gastric
contents.
Sodium citrate is a non-particulate
antacid used to neutralize gastric
contents.
Ranitidine is an H2 antagonist used to
prevent gastric acid secretion.
Allowing clear fluids up to 4 hours prior to
suregry has been shown to decrease the
gastric content volume so decreasing the
risk of aspiration.
Glycopyrollate is an anti-sialogogue used
for preoperative preparation when an
awake intubation is anticipated.

MCQ 6: All are suitable

techniques for pain relief in
labor EXCEPT:

A. Transcutaneous electrical nerve

stimulation
B. White noise
C. Epidural bupivacaine
D. Intrathecal narcotics
E. 70% Nitrous oxide in Oxygen

MCQ 6: All are suitable

techniques for pain relief in
labor EXCEPT:

A. Transcutaneous electrical nerve

stimulation
B. White noise
C. Epidural bupivacaine
D. Intrathecal narcotics
E. 70% Nitrous oxide in Oxygen

The concentration of nitrous oxide

in oxygen when used for
analgesia is 50%. Higher
concentrations can result in loss
of consciousness.

MCQ 7: Which of the following

is a contraindication to epidural
analgesia in labor:

A. Previous caesarean section

B. Fetal distress
C. INR 1.6
D. Maternal exhaustion
E. Maternal multiple sclerosis

MCQ 7: Which of the following

is a contraindication to epidural
analgesia in labor:

A. Previous caesarean section

B. Fetal distress
C. INR 1.6
D. Maternal exhaustion
E. Maternal multiple sclerosis

Epidural analgesia is not contraindicated

in patients who have had a prior C/S. The
pain caused as a result of uterine rupture
is not effectively masked by epidural
analgesia.
Fetal distress can be reduced by epidural
analgesia so long as hypotension is
avoided
Maternal exhaustion is an indication for
epidural analgesia.
Maternal multiple sclerosis is not a
contraindication to epidural analgesia as
long as the concentration of local
anesthetic is reduced
Coagulopathy is an absolute
contraindication to epidural analgesia

MCQ 8 : Likely complications of

epidural opioids include all of
the following, EXCEPT:

A. Itching
B. Urinary retention
C. Hypotension
D. Respiratory depression
E. Nausea

MCQ 8 : Likely complications of

epidural opioids include all of
the following, EXCEPT:

A. Itching
B. Urinary retention
C. Hypotension
D. Respiratory depression
E. Nausea