Dr. John Snow popularized the use of pain relief during labor and delivery when he administered chloroform to Queen Victoria for the birth of her eighth child. Labor pain is severe, comparable to other severe pains like fractured bones or cancer. Regional anesthesia techniques were introduced in 1900 and have since evolved to effectively manage labor pain, allowing women to participate more fully in the birthing experience.

1. OBSTETRICAL
ANESTHESIA

2. Dr. John Snow
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born 15 March 1813 in York,
England.Queen Victoria was given
chloroform by John Snow for the birth
of her eighth child and this did much to
popularize the use of pain relief in
labor.

3. Why have a Caregiver dedicated to pain
management during
labor and delivery?
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4. • Labor and delivery result in severe pain for most women.
• In an attempt to quantify this pain, parturients were asked to rate
their pain during labor.
• These results were then compared to values obtained from
patients in a general pain clinic and emergency department.
• The pain of childbirth was greater than a fractured arm and
cancer pain.
• Only causalgia and amputation of a digit exceeded the pain of
labor and delivery.
• Parturients described the pain as sharp, cramping, aching,
throbbing, stabbing, hot, shooting, and tight.
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5. What is the cause of labor pain in
stage 1? What type of pain is it?
• The pain resulting from the first stage of labor is
primarily due to dilatation of the cervix with
consequent distention and stretching.
• As the uterus contracts, the fetal head pushes against
the cervix and causes dilatation.
• Therefore, stage 1 pain generally occurs only during
uterine contraction.
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6. • While the majority of pain during this stage occurs
from the fetal head pushing against the cervix,
there is also pain from pressure and stretching of
the uterine muscles, which activate the high-
threshold mechanoreceptors.
• In the first stage of labor, the pain is visceral.
• It is strong and dull, and occurs over the lower
abdomen between the umbilicus and the symphysis
pubis, laterally over the iliac crest, and posteriorly
in the skin and soft tissue over the lower lumbar
spines.
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7. • Second-stage pain occurs as the fetus descends through
the birth canal.
• This results in stretching and tearing of fascia, skin, and
subcutaneous tissue.
• This somatic pain is transmitted primarily through the
pudendal nerve.
• The pudendal nerve is derived from the anterior
primary divisions of sacral nerves, S2 S3 and S4.
• Of note, the fetus often begins to descend during the
first stage of labor.
• During the transitional stage of the first stage, it is not
uncommon for the mother to experience both visceral
and somatic pain 9/3/2013
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8. Pain Pathways of Labor
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9. 9/3/2013
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Pathways of labor pain

10. Pain is caused by,
Unpleasant feeling to the mother
Maternal exhaustion – maternal acidosis fetal acidosis
Catecholamine release
Maternal sympathetic over activity
HR, BP, Coronary blood flow
Uterine blood flow & fetal hypoxia

11. Introduction
Anesthesia complications caused 1.6 percent of pregnancy-related
maternal deaths
Several factors likely have contributed to improved safety of
obstetrical anesthesia;
the recent trend toward increased use of regional analgesia, rather
than general anesthesia, may be the most significant factor.
The increased availability of in-house anesthesia coverage almost
certainly is another important reason
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12. Maternal Risk Factors That Should Prompt
Anesthesia Consultation
Marked obesity
Severe edema or anatomical abnormalities of face, neck, or spine, including
trauma or surgery
 Abnormal dentition, small mandible, or difficulty opening mouth
Extremely short stature, short neck, or arthritis of the neck
 Goiter
Serious maternal medical problems, such as cardiac, pulmonary, or
neurological disease
Bleeding disorders
Severe preeclampsia
 Previous history of anesthetic complications
Obstetrical complications likely to lead to operative delivery—e.g., placenta
previa or higher-order multiple gestation
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13. Goals of Labour Analgesia
• Dramatically reduce pain of labor
• Should allow parturient to participate in birthing
experience
• Minimal motor block to allow ambulation
• Minimal effects on fetus
• Minimal effects on progress of labor
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14. What Anesthetist Should Know
• In order for your anesthetist to determine which type of anesthesia is best
for you and your baby, it is important that you inform your anesthetist
about:
• Food and drink intake for the last several hours.
• History of difficulty breathing after anesthesia.
• History of lower back problems.
• Family history of high fevers.
• Any respiratory problems such as asthma, bronchitis, pneumonia, or if you
have a cold, sore throat or flu.
• Special medical concerns such as cardiac disease, diabetes, asthma, and
other medical conditions
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15. Types of Labor Analgesia
1. Non-pharmacological analgesia
2. Pharmacological
3. Regional Anesthesia/Analgesia
4. General Anesthesia
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16. NONPHARMACOLOGICAL
METHODS
OF PAIN CONTROL
Fear and the unknown potentiate pain.
Make a woman who is free from fear, and develop confidence in
the obstetrical staff that cares for her
Avoid emotional tension
teaching pregnant women relaxed breathing and their labor
partners psychological support techniques.
Motivatation
the presence of a supportive spouse
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17. ANALGESIA AND SEDATION
DURING LABOR
• When uterine contractions and cervical dilatation cause discomfort,
pain relief with a narcotic such as meperidine, plus one of the
tranquilizer drugs such as promethazine, is usually appropriate.
• With a successful program of analgesia and sedation, the mother
should rest quietly between contractions.
• In this circumstance, discomfort usually is felt at the acme of an
effective uterine contraction, but the pain is generally not unbearable.
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18. Neuraxial Opioids
The following opioids have been used:
Morphine, fentanyl, sufentanil, meperidine,
diamorphine.
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19. Pharmacological
Opioids
•Pethidine 75mg IM 4-6 hourly (1mg/kg)
•With(antiemetic) promethazine25mg IM
•S/E nausea
vomiting
delayed gastric emptying
respiratory depress(reversed by Naloxon)
maternal drowsiness & sedation
• Morphinealso can be used, but S/E more
(Respiratory depress)

20. Parenteral Agents
Meperidine and Promethazine
 Meperidine, 50 to 100 mg, with promethazine, 25 mg,
may be administered intramuscularly at intervals of 2 to 4
hours.
 A more rapid effect is achieved by giving meperidine
intravenously in doses of 25 to 50 mg every 1 to 2 hours.
Whereas analgesia is maximal about 30 to 45 minutes
after an intramuscular injection, it develops almost
immediately following intravenous administration.
Meperidine readily crosses the placenta, and the half-life
is approximately 13 hours or longer in the newborn
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21. Butorphanol (Stadol)
This synthetic narcotic, given in 1- to 2-mg doses,
compares favorably with 40 to 60 mg of meperidine.
The major side effects are somnolence, dizziness, and
dysphoria.
Neonatal respiratory depression is reported to be less than
with meperidine, but care must be taken that the two drugs
are not given contiguously because butorphanol
antagonizes the narcotic effects of meperidine
a sinusoidal fetal heart rate pattern following butorphanol
administration 9/3/2013
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22. Fentanyl
This short-acting and potent synthetic opioid may
be given in doses of 50 to 100mcg intravenously
every hour.
Its main disadvantage is a short duration of
action, which requires frequent dosing or the use
of a patient-controlled intravenous pump.
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23. Efficacy and Safety of Parenteral Agents
• Meperidine is the most common opioid used worldwide for pain
relief in labor.
• There is no convincing evidence demonstrating that alternative
opioids are better.
• There is no evidence that parenteral opioids influence the length of
labor or need for obstetrical intervention.
• Epidural analgesia provides superior pain relief.
• Intravenous and intramuscular sedation are not without risks.
 maternal anesthetic-related deaths were from such sedation-aspiration,
inadequate ventilation, and overdosage.
 Moreover, meperidine or other narcotics used during labor may cause newborn
respiratory depression. 9/3/2013
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24. Inhalational analgesia
• N2O in the form of Entonox
Quick onset(1-2min), short duration of effect (2-
8min ) start inhaling at the onset of a contraction
• Not suitable for prolong use of early labour
because hyperventilation can cause hypocapnoea,
dizziness & ultimately fetal hypoxia

25. Nitrous Oxide
The use of intermittent nitrous oxide for labor pain ,the following
technique suggested:
1)Instruct the woman to take slow deep breaths and to begin inhaling 30
seconds before the next anticipated contraction and to cease when the
contraction starts to recede.
2)Remove the mask between contractions and encourage her to breathe
normally. No one but the patient or knowledgeable personnel should hold
the mask.
3)Instruct a caregiver to remain in verbal contact with the patient.
4)Provide the expectation that the pain will likely not be eliminated, but that
the gas should provide some relief.
5)Ensure intravenous access, pulse oximetry, and adequate scavenging of
exhaled gases.
6)Use with additional caution after previous opioid administration because
the combination can more easily render a woman unconscious and unable
to protect her airway. 9/3/2013
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26. Regional Analgesia
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27. Regional anesthetic
techniques, were
introduced to obstetrics
in 1900, when Oskar
Kreis described the use
of spinal anesthesia.
Unfortunately he was an
obstetrtian
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28. Regional Analgesia
Various nerve blocks have been developed over the
years to provide pain relief during labor and delivery.
They are correctly referred to as regional analgesics.
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29. Regional Anesthesia/Analgesia
• Epidural
• Spinal
• Combined Spinal Epidural (CSE)
• Continuous spinal analgesia
• Paracervical block
• Lumbar sympathetic block
• Pudendal block
• Perineal infiltration
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30. Pudendal Block
• This block is a relatively safe and simple method of
providing analgesia for spontaneous delivery.
• The end of the introducer is placed against the vaginal
mucosa just beneath the tip of the ischial spine.
• The needle is pushed beyond the tip of the director into
the mucosa and a mucosal wheal is made with 1 mL of 1-
percent lidocaine solution or an equivalent dose of another
local anesthetic.
• To guard against intravascular infusion, aspiration is
attempted before this and all subsequent injections.
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31. Pudendal Block
The needle is then advanced until it touches the sacrospinous ligament,
which is infiltrated with 3 mL of lidocaine.
The needle is advanced farther through the ligament, and as it pierces
the loose areolar tissue behind the ligament, the resistance of the
plunger decreases. Another 3 mL of the anesthetic solution is injected
into this region.
Next, the needle is withdrawn into the introducer, which is moved to
just above the ischial spine. The needle is inserted through the mucosa
and the rest of 10 mL of solution is deposited. The procedure is then
repeated on the other side.
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32. 9/3/2013
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33. Pudendal Block
Within 3 to 4 minutes of the time of injection, the successful pudendal
block will allow pinching of the lower vagina and posterior vulva
bilaterally without pain.
It is often of benefit before pudendal block to infiltrate the fourchette,
perineum, and adjacent vagina with 5 to 10 mL of 1-percent lidocaine
solution directly at the site where the episiotomy is to be made.
Then, if delivery occurs before pudendal block becomes effective, an
episiotomy can be made without pain.
By the time of the repair, the pudendal block usually has become
effective.
Pudendal block usually does not provide adequate analgesia when delivery
requires extensive obstetrical manipulation.
Moreover, such analgesia is usually inadequate for women in whom
complete visualization of the cervix and upper vagina, or manual
exploration of the uterine cavity, are indicated. 9/3/2013
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34. Complications of Pudendal Block
Central Nervous System Toxicity , intravascular injection of a
local anesthetic agent may cause serious systemic toxicity.
Hematoma formation
Rarely, severe infection may originate at the injection site. The
infection may spread posterior to the hip joint, into the gluteal
musculature, or into the retropsoas space.
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35. Paracervical Block
This block usually provides satisfactory pain relief during the first
stage of labor.
Because the pudendal nerves are not blocked, however, additional
analgesia is required for delivery.
Usually lidocaine or chloroprocaine, 5 to 10 mL of a 1-percent
solution, is injected into the cervix laterally at 3 and 9 o'clock.
 Bupivacaine is contraindicated because of an increased risk of
cardiotoxicity.
Because these anesthetics are relatively short acting, paracervical
block may have to be repeated during labor.
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36. Complications Of Paracervical Block
Fetal bradycardia(15%)
Bradycardia usually develops within 10 minutes and
may last up to 30 minutes.
The effect may be the consequence of transplacental
transfer of the anesthetic agent or its metabolites and
in turn, a depressant effect on the fetal heart.
For these reasons, paracervical block should not be
used in situations of potential fetal compromise.
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37. Spinal (Subarachnoid) Block
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38. Spinal Anesthesia/Analgesia
• Used mainly for very late
in labor because it has
limited duration of action
• Faster onset than Epidural
• Amount of local
anesthetic used is much
smaller
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39. Spinal Anaesthesia
• A fine gauge atraumatic spinal needle is inserted in to the
subarachnoid space
• Small volume of local
anaesthetic is injected, after
which the spinal needle is
withdrawn
• Not used for routine analgesia
in labour
• Combined spinal- epidural analgesia?

40. Spinal (Subarachnoid) Block
• Introduction of a local anesthetic into the subarachnoid space to
effect analgesia has long been used for delivery.
• Advantages include a short procedure time, rapid onset of the
block, and high success rate.
• Because of the smaller subarachnoid space during pregnancy,
likely the consequence of engorgement of the internal vertebral
venous plexus, the same amount of anesthetic agent in the same
volume of solution produces a much higher blockade in
parturients than in nonpregnant women.
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41. Contraindications to Spinal Analgesia
• Obstetrical complications that are associated with maternal
hypovolemia and hypotension—such as severe hemorrhage—are
contraindications to the use of spinal block.
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42. Epidural Analgesia
Provides excellent pain relief reducing
maternal catecholamines
Ability to extend the duration of block to
match the duration of labor
Blunts hemodynamic effects of uterine
contractions: beneficial for patients with
preeclampsia.
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43. Epidural analgesia
• Epidural catheter inserted at the level of L2-L3
L3-L4 or L4-L5 interspace & to the epidural space.
• Catheter is aspirated to check the position
• Test dose given to confirm the catheter position
small volume of diluted local anaesthetic (10-15ml)
• After 5mins loading dose of mixture of 0.1%
Bupivacaine with fentanyl 12mcg/ml is given
• Prepare ephedrine for IV injection(30mg diluted in
9mg of saline or water)
• Infusion of epidural solution 6-12ml/hr

44. Indications for LEA
 PAIN EXPERIENCED BY A WOMAN IN
LABOR
 When medically beneficial to reduce the stress
of labor
 ACOG and ASA stated
“ in the absence of a medical contraindication,
maternal request is a sufficient medical
indication for pain relief…”
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45. Important…
• Secure IV access
• Establishment/after each bolus measure BP every 5min for 15min
• Every hour; check level of sensory block.
• Continue until completion of the 3rd stage & any perineal repair.
• Birth should take place within 4hours.

46. Contraindications
• Coagulation disorders
• Local or systemic sepsis
• Hypovolamia
• Insufficient no.of trained staff

47. Complications
• Accidental dural puncture-leak of CSF causing spinal headache
• Accidental total spinal anaesthesia -severe hypotension, respiratory
failure, unconsciousness & death
• Drug toxicity occur with
accidental placement of catheter
within a blood vessel
• Bladder dysfunction
• Short term respiratory distress in
baby

48. Obstetric conditions where epidural analgesia is
more likely to be indicated:
• Pre eclampsia/hypertensive disease
• Prolonged labour
• Two or more babies inutero
• Anticipated instrumental delivery
• Diabetes Mellitus
• Breech presentation for vaginal delivery
• Significant respiratory disease
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49. 9/3/2013
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50. 9/3/2013
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51. Standard Technique of LEA
4. Maternal position ( sitting or lateral?)
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52. Comparison of Sitting and Lateral Positions for
Performing Spinal or Epidural Procedures
Sitting Lying (left lateral)
Advantages
• Midline easier to identify in obese
women
• Obese patients may find this position
more comfortable
• Can be left unattended without risk of
fainting.
• No orthostatic hypotension
• Uteroplacental blood flow not reduced
(particularly important in the stressed
fetus)
Disadvantages
• Uteroplacental blood flow decreased
• Orthostatic hypotension may occur
• Increased risk of orthostatic
hypotension if Entonox and pethidine
have been administered
• Assistant (or partner) needed to support
patient
• May he more difficult to find the
midline in obese patient
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53. 9/3/2013
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54. 9/3/2013
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55. Cont…
• Women receiving prophylactic doses of unfractionated heparin
or low-dose aspirin are not at increased risk and can be offered
regional analgesia.
• For women receiving once-daily low-dose low-molecular-weight
heparin, regional analgesia should not be placed until 12 hours
after the last injection.
• Low-molecular-weight heparin should be withheld for at least 2
hours after the removal of an epidural catheter.
• The safety of regional analgesia in women receiving twice-daily
low-molecular-weight heparin has not been studied sufficiently.
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56. Combined Spinal–epidural
Techniques
• may provide rapid and effective analgesia for labor as well as for
cesarean delivery.
• an introducer needle is first placed in the epidural space. A small-
gauge spinal needle is then introduced through the epidural needle
into the subarachnoid space—this is called the needle-through-needle
technique.
• A single bolus of an opioid, sometimes in combination with a
local anesthetic, is injected into the subarachnoid space, the spinal
needle is withdrawn, and an epidural catheter is then placed. The
use of a subarachnoid opioid bolus results in the rapid onset of
profound pain relief with virtually no motor blockade.
• The epidural catheter permits repeated dosing of analgesia.
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57. Combined spinal epidural (CSE)
 Initial reports: two interspace technique-
epidural followed by spinal
Later evolution of CSE in the direction of
needle through needle technique
Postdural puncture headache: 1% or less
incidence for CSE with small bore atraumatic
needles.
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58. Advantages of CSE for Labor
Analgesia
 Rapid onset of intense analgesia (the patient loves
you immediately!)
 Ideal in late or rapidly progressing labor
 Very low failure rate
 Less need for supplemental boluses
 Minimal motor block (“walking epidural”)
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59. 9/3/2013
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60. Combined Spinal epidural
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61. Espocan CSE Needle (B. Braun)
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62. Espocan CSE Needle (B. Braun)
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63. Eldor needle
Combined Spinal Epidural for Obstetric Anesthesia.flv
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64. Maintenance of epidural analgesia can be achieved by:
 regular top-ups
 an epidural infusion
 patient-controlled epidural analgesia (PCEA).
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65. Intermittent bolus injections:
 Bupivacaine: 0.125%-0.375%, 5-10 ml, duration:1-2
hr
 Ropivacaine: 0.125%-0.25%, 5-10 ml, duration: 1-2
hr
 Lidocaine: 0.75%-1.5%, 5-10 ml, duration: 1-1.5 hr
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66. Patient Preparation
• Prior to anesthesia induction, several steps should be
taken to help minimize the risk of complications for the
mother and fetus. These include the
use of antacids,
 lateral uterine displacement, and
preoxygenation.
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67. Induction of Anesthesia
Thiopental
Ketamine
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68. Thiopental
• This thiobarbiturate given intravenously is widely used and offers
the advantages of ease and extreme rapidity of induction as well as
prompt recovery with minimal risk of vomiting.
• Thiopental and similar compounds are poor analgesic agents, and
the administration of sufficient drug given alone to maintain
anesthesia may cause appreciable newborn depression.
• Thus, thiopental is not used as the sole anesthetic agent, but rather
is administered in a dose that induces sleep.
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69. Ketamine
• This agent also may be used to render the patient unconscious.
• Given intravenously in low doses of 0.2 to 0.3 mg/kg, ketamine
may be used to produce analgesia and sedation just prior to vaginal
delivery.
• Doses of 1 mg/kg induce general anesthesia.
• Ketamine may prove useful in women with acute hemorrhage
because, unlike thiopental, it is not associated with hypotension.
• Conversely, it usually causes a rise in blood pressure, and thus it
generally should be avoided in women who are already
hypertensive.
• Unpleasant delirium and hallucinations are commonly induced by
this agent. 9/3/2013
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70. Intubation
• Immediately after the patient is rendered unconscious, a muscle
relaxant is given to facilitate intubation.
• Succinylcholine, a rapid-onset and short-acting agent, commonly is
used.
• Cricoid pressure—the Sellick maneuver—is used to occlude the
esophagus from induction until intubation is completed by a
trained assistant.
• Before the operation begins, proper placement of the
endotracheal tube must be confirmed.
• Such confirmation includes auscultation of bilateral breath
sounds and end-tidal carbon dioxide analysis.
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71. 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.
Even in cases where the initial assessment of the airway was
uneventful, edema may develop intrapartum and present
considerable difficulties.
 Morbid obesity is also a major risk factor for failed or difficult
intubation.
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72. Management of failed intubation
 start the operative procedure only after it has been
ascertained that tracheal intubation has been successful
and that adequate ventilation can be accomplished.
Even with an abnormal fetal heart rate pattern,
initiation of cesarean delivery will only serve to
complicate matters if there is difficult or failed
intubation.
 Frequently, the woman must be allowed to awaken and
a different technique used, such as an awake intubation
or regional analgesia. 9/3/2013
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73. • 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.
• In those cases where the woman has been paralyzed, and where
ventilation cannot be reestablished by insertion of an oral airway,
laryngeal mask airway, or use of a fiberoptic laryngoscope to
intubate the trachea, a life-threatening emergency exists.
• To restore ventilation, percutaneous or even open cricothyrotomy
is performed, and jet ventilation begun.
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74. What anesthetic options are available for cesarean delivery?
What options are available for pain control following cesarean
delivery?
What anesthetic risks accompany preeclampsia?
Is fetal outcome any different between regional and general
anesthesia?
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75. 9/3/2013
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Anesthesia for Cesarean
Section

76. Anesthesia for Cesarean Section
The choice of anesthesia depend on:
• The indication for the CS
• The urgency of the procedure
• The medical condition of the mother and the fetus
• The desire of the mother
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77. Anesthesia for Cesarean Section
• GA associated with higher risk of airway
problems .
• Incidence of failed tracheal intubation in
pregnant women is 1 in 200 to 1 in 300 cases
Anesthesia2000;55:690-4
• Maternal death due to anesthesia is the sixth
leading cause of pregnancy related death in USA
Obstet Gynecol 1996;88:161-7
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78. Anesthesia for Cesarean Section
• The risk of maternal death from complications
of GA is 17 times as high as that associated with
Regional anesthesia
• In USA the shift from GA to RA for CS resulted
in decrease in anesthesia related maternal
mortality from 4.3 to 1.7 per 1 million live birth
Anesthsiology 1997;86:277-84
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79. Epidural anesthesia
• Advantage
– Titration (volume dependent, not gravity dependent), decreased
likelihood of hypotension
– Incremental dose (for longer operation)
• Disadvantage
– Dural puncture :1/200-1/500 in experienced hands, higher in
training institution
– If unintentional dural puncture, PDPH incidence is 50-85%
– Slower onset
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80. Spinal anaesthesia
• Hyperbaric bupivacaine 0.5% is the drug most commonly
used for spinal anaesthesia for Caesarean section.
• Pregnant patients require a smaller dose than the
nonpregnant population (why?)
• The dose used via a standard lumbar approach is typically
2.0–2.75 ml.
no significant correlation between age, height, weight, body mass
index and length of vertebral column and the final block height
achieved
Anesthesiology1990; 72: 478–482.
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81. Combined spinal epidural(CSE)
Combines the rapid onset and efficacy of the
spinal technique with the ability to:
Extend anaesthesia if surgery is prolonged
Provide excellent postoperative epidural
analgesia.
Combined Spinal Epidural for Obstetric Anesthesia.flv
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82. Optimal Neuraxial Medication
Combinations for Cesarean Delivery
Medication Spinal Epidural
Local anesthetic Bupivacaine 12 mg
(range 9–15)
Lidocaine 2%;
Fentanyl 15–35 ug 50–100 ug
Morphine 0.1 mg 3.75 mg
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83. Complications of Regional
Anesthesia
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84. Complications of regional
anesthesia
Post Dural Puncture Headache (PDPH)
 severe, disabling fronto-occipital headache with
radiation to the neck and shoulders.
 present 12 hours or more after the dural puncture
 worsens on sitting and standing
 relieved by lying down and abdominal compression.
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85. Complications of regional
anesthesia
PDPH syndrome
1. Photophobia
2. Nausea
3. Vomiting
4. Neck stiffness
5. Tinnitus
6. Diplopia
7. Dizziness
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