Anesthesia for the Obstetrical Patient

Posted by e-Medical PPT Friday, July 22, 2011
Goals of Labor Analgesia
Adequate Analgesia
Allow the mother to participate in birthing experience
Minimal effect on the fetus
Minimal effect on the progress of labor

Neuraxial Blockade
A well conducted block provides the most effective and least depressant analgesic
Spinal opiate (single shot) – fast onset, limited duration
Continuous Epidural – slower onset, but duration is adjustable. Potential motor block.
Combined Spinal Epidural – best of both

Arguments for epidural for Labor
Relative risk of maternal mortality during C-section was 16x greater with GA compared to regional anesthetic
Epidural for labor is now used in ~2.4m of the 4m total births in the US per year

Disadvantages of epidural analgesia for labor
Slows labor by approximately one hour
Questionable effect on Cesarean Section delivery rate
Increases use of instruments during vaginal delivery
Increased incidence of maternal fever (and subsequent fever workup of mom and child)

Combined Spinal – Epidural Analgesia
Most beneficial in early or late labor (especially the multiparous patient)
#27 spinal needle through epidural needle – followed by epidural catheter insertion
Almost immediate pain relief with spinal opiate (fentanyl 10-25ug or sufentanil 2.5-10ug)
2-3 hour duration of analgesia with the spinal opiate
Patient may ambulate
In early labor (<4 cm dilation) CSE promotes more rapid cervical dilation than IV hydromorphone.
Also, high concentrations of local anesthetic slow labor

Problems with Intrathecal Opiates
Pruritus – usually mild and short lived
Nausea and vomiting – best treatment?
Hypotension
Urinary retention
Uterine hyperstimulation and fetal bradycardia? (studies show no increased risk)
Maternal respiratory depression – monitor for at least 20 minutes post injection....

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