ANALGESIA and ANESTHESIA in Labor and Delivery

dr. Adhitya Maharani Devi, M.Kes, SpOG

Pain Pathways and The Stages of Labor

The first stage of labor :
Begins with the onset of regular contraction and ends with the cervix being completely dilated The pain is conducted via the T10 to L1 nerve roots

The Second stage of labor :

Begins at full cervical dilatation and ends with the delivery of the infant The pain caused by distention of the vulva and perineum, is conducted by the pudendal nervia the S2 to S4 nerve roots

Three essensial of obstetrical pain relief

Simplicity Safety Preservation of fetal homeostatis The women who is given any form of analgesia should be monitored closely Risk vary according to the type of analgesia selected

Anesthetic Risk Factors in Pregnant Women

1 2 3 4 5 6 7 8 Marked obesity Severe edema or anatomical anomalies of the face and neck Protuberant teeth, small mandible, or difficulty in opening the mouth Short stature, short neck or arthritis of the neck Large thyroid Asthma, chronic pulmonary disease or cardiac disease Bleeding disorders Severe preeclampsia-eclampsia

9
10

Previous history of anesthetic complication

Other significant medical or obstetrical complication

Pain Relief During Labor and Delivery

A. PARENTRAL MEDICATION

1. SEDATIVE TRANQUILIZERS
Generally used during the first stage labor Often in conjunction with narcotic Barbiturates is generally restricted to the early stage because of depressant effect on the neonate The phenothiazines, promethazine and hydroxyne are efeffective in reducing anxiety without causing neonatal depression

Diazepam (valium), has been safely used in small doses to relieve extreme maternal anxiety without producing significant adverse neonatal effect Midazolam also a benzodiazepine, can cause retrograde amnesia that is undesirable at the time of birth

2. NARCOTIC
Used to provide pain relief during labor and to supplement regional and general anesthesia during a cesarean delivery Side effect :
Some degree of respiratory depression Orthostatic hypotension Nausea and vomiting Transferred rapidly across the placenta and cause neonatal respiratory depression

Meperidine (Demerol) : Currently the most commonly used narcotic in obstetric It has repleassed morphine as an obstetric analgesic, because of the latters prolonged duration of action and greater neonatal respiratory depression Fentanyl : As adjuvant for both regional and general anesthesia for cessarian delivery The use of IV for analgesia during labor is currently under investigation The synthetic narcotic agonist-antagonist, butophanol and nalbuphine, cause on limited respiratory depression, makingthem useful for labor analgesia Side effect : Dizziness or drowsiness Unsuitable for ambulating patient

3. DISSOCIATIVE DRUG AND NEUROLEPTANALGESIA

DISSOCIATIVE DRUG
Ketamine and scopolamine Rarely used as sedative during labor

NEUROLEPTANALGESIA
Using a combination of a narcotic and a major tranquilizer (i,e, fentanyl and droperidol) is not a popular technique Potensial for profound neonatal depression

B. REGIONAL ANALGESIA FOR LABOR AND DELIVERY

1. CLASSIFICATION OF BLOCK

a. The Lumbar epidural block

The most popular forms of analgesia during labor Can be performed as a single injection (when the cervix is fully dilated and the fetal head are in position for delivery) Or as a continuous technique consisting of intermittent boluses of local anesthesia through an epidural catheter (usually initiated when cervical dilatation reaches 4 to 6 cm)

Capable of providing uninterrupted analgesia throughout labor & delivery Monitoring maternal BP and FHR A low concentration of combined local anesthetic & narcotic via continuous infusion providing a continuous and stable level of anesthesia with fewer occurences of hipotensive episodes while better maintaining pelvic muscle tone An increase in cesarean delivery rates when epidurals are administered before 5 cm of dilatation

b. The Caudal Block

A form of epidural analgesia in which the epidural space is entered through the sacral hiatus Less frequently used for vaginal delivery, because less effective in providing analgesia during the first stage of labor and is more painful to administer. More local anesthetic agent, thus increasing the risk of total spinal anesthesia should dural puncture. Puncture of the fetal head and injection into the fetus Rectal examination should be performed to rule out this possibility Perineal anesthesia and muscle relaxation are more rapid

c. The Subarachnoid (Spinal) Block

Not commonly used for vaginal delivery Because the urge to bear down is abolished and the mother is unable to cooperate in the delivery. Excellent anesthesia for cesarean delivery

d. The Paracervical Block

Used for pain relief during the first stage of labor Generally performed when the cervix is dilated 4 to 6 cm in the multiparous and 5 to 6 cm in primiparous Fetal bradycardia is the most common and serious complication and the incidence may be as high as 50% Should not be done in the presence of impaired uteroplacental circulation or if the fetus is at risk

e. The Pudendal Block

For pain relief during the second stage of labor Produces adequate perineal analgesia for outlet forceps delivery as well as episiotomy and repair For optimal effect administered at the start of the second stage of labor in the primiparous and at 6 to 8 cm dilatation in the multiparous

f. The Local Block

Generally used before an episiotomy is done during vaginal delivery

EFFECT OF REGIONAL ANESTHESIA ON LABOR AND DELIVERY

Because of the number of variable present in any given delivery The effect of regional analgesia on the progress and outcome is difficult to ascertain. Epidural analgesia has minimal effect on duration or quality of the first stage labor if hypotension is avoided and uterine displacement is maintained Epidural analgesia increased the duration of the second phase of the labor as well as increasing the frequency of instrumental delivery

This effect can be minimized through the use of more dilute concentration of local anesthetics in combination with low dose of narcotic (fentanyl/sufentanil) using a continous infusion technique The administration of a perineal dose of local anesthesia just before delivery result in an increased of instrumental delivery

C. INHALATION ANESTHETICS FOR LABOR AND DELIVERY

Nitrous oxide (N2O) has been found to have little effect on the uterus The halogenated agent (Halothane,flurane,isoflurane) can produce profound, dose dependent uterine relaxation General anesthesia can be used to relax the uterine during tetanic contraction or to facilitate uterine manipulation Such relaxation can lead to increased blood loss, this effect can be reversed by the administration of oxytocin

D. ANESTHESI FOR CESAREAN DELIVERY

1. REGIONAL
Spinal and Epidural anesthesia The use of RA technique allows for:
A decreased risk of pulmonarya aspiration (compared with GA) Decreased the risk of neonatal respiratory depression by lessening the need for systemic narcotic The mother is awake and able to participate may enhance the birth experience

The disadvantages RA include :

The possibilities of a prolonged onset time (compared with GA) Spinal headache Maternal hypotension with resulting fetal hypoxia

Contraindication :
Patient Refusal Hypovolemic shock UPI Septicemia or infection at the site of injection Coagulation disorders (including HELLP syndrome Neurologic disorders, such as mutiple sclerosis Preeclampsia maternal hypotension decrease in uteroplacental perfusion and fetal asphyxia.

Immediate Complication of Epidural Analgesia

High or total spinal Hypotention Urinary retention

Headache
Postdural puncture seizure Meningitis Cardiorespiratory arrest Vestibulocochlear dysfunction

2. GENERAL
The major advantage :
The Speed in which it can be administreted and in which a distressed fetus can be delivered Less maternal hypotension Has greater cardiac stability and allows for control of the airway and ventilation Preferable in patient with coagulopathies, preexisting neurologic disease, local infection or generalized sepsis

The disadvantage :
Increased posibility of aspiration pneumonitis in the pregnant patient maintenance of maternal ventilation and oxygenation and prevention of maternal hypotension The insidence of difficult or failed intubation is much higher in the obstetric surgical patient

ANESTHETIC CONSIDERATION IN THE PREGNANT PATIENT

Tetatogenic in human ?? fetal exposure to any drug should be minimized, especially during the first trimester Elective surgery be postponed until 6 weeks postpartum If possible, surgery should be postponed until the second or third trimester Regional anesthesia technique selected to minimize fetal exposure to drugs If GA with N2O is to be employed, consider pretreating with folinic acid because N2O inactivate vit B12, with is essensial in folate metabolism and thymidine synthesis

After the sixteenth w.o.g continuous FHR monitoring & Uterine contraction to detect preterm delivery The pregnant or postpartum patient has an increased risk of aspiration of gastric content preoperative administration of antacids, dopamine agonist (metoclopramide) or H2receptor antagonist (famotine), Anticholinergics (atropine,scopolamine) has not been shown to effectively to decrease. When GA is required, the airways must be protected via placement of endotracheal tube

Skill tracheal intubation accompanied by pressure on the cricoid cartilage to occlude the esophagus The Sellick maneuver.

LOCAL ANESTHETIC AGENT

A.Mechanism of Action
Local anesthetic agents blok the sodium channels in the nerve membrans, thus impairing propagation of the action potensial in axons In general, myelinated fibers are more readily blocked than non myelinated, and the thinner fibers are more easily blocked then thick ones

B. Types of Local Anesthetic

Local anesthetics are classified as :
Esters (procain, chloroprocaine, tetracaine) Amides (bupivacaine,etidocaine,lidocaine,mepivacaine)

The esters are motabolized by plasma cholinesterase and thus have short half-lives in circulation Paraamino benzoic acid, a degradation product of ester metabolism, can cause a hypersensitivity reaction in susceptible individuals Amide local anesthetics are metabolized primarily in the liver

C. Ester Local Anesthetic Agent

Procaine (Novocain) is a short acting agent used for local infiltration and spinal anesthesia Chloroprocaine (Nesacaine) is a short acting agent used for local infiltration and epidural anesthesia Rapid hydrolysis of this agent by plasma cholinesterase makes this the least cardiotoxic of the local anesthetics

Arachnoiditis and neurotoxicity with this agent are now attributed to the preservative metabisulfite, which has been replaced with EDTA This new formulation cause severe backache when dosage exceeds 25 ml of solution Chloroprocaine or one of its metabolites can impair the action of other epidural agents, such as bupivacain or fentanyl Tetracaine is along-acting agent used primarily for spinal anesthesia

D. Amide Local Anesthetic Agents

Bupivacaine (Marcaine, Sensorcaine) can be used for all form of local and regional anesthesia It provides a sensory block of high quality (in relation to the degree of motor blockade) and long duration Its slow onset of action (up to 30 minutes) can make it impractical for urgent procedurs

Intravascular injection of bupivacaine can result in cardiac arrest that is resistent to treatment pregnant patients in labor are more susceptible to this effect and 0.75% is contraindicated for epidural anesthesia or obstetric practice Lidocaine (Xylocain) is the most frequently used local anesthetic for all form of local and regional anesthesia. Although lidocain does have a high rate of placental transfer, Apgar scores are statistically unaffected.

Mepivacaine (Carbocaine) is used for local infiltratration, nerve block and epidural anesthesia with a duration of action slightly longer than lidocaine It has an increased half-life in the neonate, which has lead to a decline in its use in obstetrics.

COMPLICATIONS OF REGIONAL ANESTHESIA

A. HYPOTENSION
The most common complication of spinal or epidural anesthesia BP must be monitored frequently because even mild reduction may adversely affect uterine blood flow. The degree and durationof maternal hypotension necessary to cause fetal distress are variable Fortunately, if hypotension from RA is promptly corrected, it has little adverse effect on neonatal outcome

To prevent maternal hypotension include hydration before administration of RA and continous left uterine displacement to minimize aortocaval compression Prophylactic of a vasopressor (ephedrine, 10 to 15 mg IV) is effective in decreasing the incidence of maternal hypotension associated of spinal anesthesia Treatment of hypotension after spinal or epidural anesthesia include

Rapid infusion of fluids Increasing left uterine displacement Administration of IV ephedrine Trendelenburg position to increase venous return The administration of supplemental oxygen to the mother will not necessarily raise fetal PaO2 if maternal hypotension is not corrected

B. TOTAL SPINAL ANESTHESIA

Can result from:
extensive spread of local anesthetic administrated subdurally Injecting the epidural dose of local anesthetic into an epidural needle or catheter that has been improperly placed or that has migrated into the subarachnoid space.

Nausea and profound hypotension may be followed by loss of consciousness and cardiac or respiratory arrest Treatment is supportive
Airway established Ventilated with oxygen Trachea intubated (using succinylcholine, 1 to 1.5 mh/kg) to prevent aspiration of gastric content Trendelenburg position with left uterine displacement Fluid and ephedrine to maintain BP Maternal bradycardia must be treated promptly by administering atropine and ephedrine. If there are ineffective, IV epinephrine should be administered In cases of cardiac arrest secondary to high spinal anesthesia, afull resuscitation dose of epinephrine should be administered immediatly

C. LOCAL ANESTHETIC CONVULSIONS

High blood level of a local anesthetic may be a result of accumulation during repeated injections or rapid systemic absorption from a highly vascular area Generally caused by the in advertent iv injectionof local anesthetic during epidural anesthesia Seizures are generally preceded by loss of consciousness.

Early recognition of this reaction is important because small doses of barbiturates (diazepam, 5 mg or thiopental 50 mg IV, repeated as necessary) may prevent convulsion Treatment is generally supportive with ventilation and circulation supported. The incidence can be decreased by judiciously aspirating needles and catheters before dosing and by routinely injecting test doses of local anesthetic with epinephrine.

D. NEUROLOGIC COMPLICATIONS
The most common complication of spinal and epidural anesthesia is the postdural pucture (spinal) headache For a spinal anest. , the incidence can be minimized by using the smallest needle posible, Prophylactic bed rest and increased hydration have little or no effect on incidence of postpuncture headache

The incidence of dural puncture with epidural anest is ussually between 1% to 2% with headache occuring almost 80% Treatment is generally supportive and consists mainly of bed rest, hydration and use of oral analgesic. IV caffeine sodium benzoate and oral caffeine have been shown to relieve these headache Severe cases might require a blood patch, which is ussually very effective