o antacid use (nonparticulate antacid,
Red- audio
Blue and purple-upclass
ANESTHESIA FOR LABOR AND
VAGINAL DELIVERY
Anesthesia is different from analgesia
Analgesia is removal of pain. Anesthesia is
to take away all sensations. Pressure and
not pain.
Main Anesthesia Concerns
Maternal Safety
Fetal Safety
Anesthesia Goals
1. Satisfactory pain relief
2. Non-interference with labor
3. Minimal risk to either mother of
fetus
-because anaesthesia is double
edge sword. Although it may take
away the pain, it can also take
away the life of the mother.
4. Provision of satisfactory conditions
for delivery
5. Early interaction between mother
and newborn
- In giving anesthesia, you dont
interfere with the interaction
between the mother and the
fetus. The patient is awake, so
that after delivery, the mother
may engage the newborn.
- Inside the body, there is no true
connection between the mother
and the fetus. The placenta is
designed in a way that it can
only allow the exchange of
nutrients and important
materials for the survival of the
fetus.
- Upon birth, it is now the true
contact between the mother
and baby.
- It is implicated by the DOH the
maternal and fetal interaction.
There is psychological
implication for this contact.
Patient Preparation:
an H2-receptor antagonist, or
metoclopramide )
o Antacids dec. acidity of
gastric juice
o Metoclopramide dec.
gastric secretions
o lateral uterine displacement - uterus
may compress the inferior vena
cava and aorta when the mother is
supine
o pre oxygenation
Mode of Delivery
1. Psychologic and non-pharmacologic
techniques
2. Parenteral agents
3. Inhalational
4. Regional anesthetic techniques
1. Non-Pharmacologic Techniques
1. Lamaze -
2. Hypnosis
3. Biofeedback
4. Muscle therapy
5. TENS (Transcutaneous Electrical
Nerve Stimulation)
6. Sterile water blocks
7. Acupuncture
8. Therapeutic touch
9. Massage therapy
10. Muscle tension release
11. Reflexology
12. Acupressure
13. Hydrotherapy
14. Herbal cocktails
15. Aromatherapy
2. Parenteral Agents
-via intravenous
3 Classes:
1. Opiods meperidine, fentanyl,
morphine, nalbuphine
2. Sedatives / Tranquilizers
phenothiazines, benzodiazepines:
(Diazepam, Lorazepam/Ativan),
dissociative medications
3. Intravenous anesthetics
barbiturates, propofol
No longer regional anesthesia
Removed na ang benzo
 decreasing anxiety and decreasing
catecholamine levels

Sedatives and Hypnotics

Barbiturates (Pentothal and
Methohexital)
Inducting agents for general
anesthesia because of rapid onset
All barbiturates are depressant to
mother and baby
If pain due to uterine contractions and
cervical dilatation:
o narcotic such as meperidine
Ketamine
(Demerol), plus
o tranquilizer drug, such as Produce dissociative analgesia,
promethazine (Phenergan) amnesia, and sedation
Truth serum because of
Opioids dissociative analgesia
Morphine, meperidine (demerol), fentanyl, Contraindicated in preeclampsia or
and subfentanil most effective systemic hypertension
analgesics Inc. blood vessel tone
-Sedatives can cause low BP
Side effects: except ketamine
1. Nausea and vomiting Incidence of hypertensive crisis
2. Orthostatic hypotension when combined with ergonotive or
3. Delayed gastric motility vasopressors
Metoclopramide given to dec. Can cause hallucinations and
intragastric vol. nystagmus; prevention: give
effect is blunted when given benzodiazepine first
with opioids
4. Maternal somnolence high doses Benzodiazepines
5. Hallucinations Diazepam(valium) and midazolam
6. Pruritus (dormicium)
Newborn respiratory depression Anxiolytics and anticonvulsants
can be reversed by using Used in small doses (5 mg and 2 mg
Naloxone (contraindicated in IV)
narcotic-addicted mother) Larger doses, both cause neonatal
Meperidine - most common hypotonia, hypothermia, delayed
opioid used worldwide for pain feeding, increased jaundice,
relief from labor kernicterus (poor APGAR scores)
- readily crosses the placenta, and its half- GABA receptor (Gamma Aminobutyric
life in the newborn is approximately 13 Acid)
hours or longer Can be given on anxious patients.
- its depressant effect in the fetus follows They tend to become hyperventilated
closely behind the peak maternal which may cause hypercarbia that
analgesic effect. leads to constriction of the uterine
Narcotics and Labor artery, thus causing atony of the
Dose-dependent reduction in the uterus. Atony is a major obstetrical
force or rate of contractions as well emergency.
as timing-dependent Can also cause dose-dependent
Biggest effect is in the latent phase respiratory depression
May speed up the progress of labor
during the active phase by 3. Inhalation Analgesia
 John Snow gave to Queen Victoria
Nitrous oxide
Analgesia during birthing and
preserves laryngeal function
Nightmare of general anesthesia
is ASPIRATION
genereal anesthesia
Cause dose-dependent uterine
relaxation
Major hazard risk of pulmonary
aspiration (Mendelsons
syndrome)
Need for special vaporizer (gives
specific dose; calibrated)
Provides incomplete analgesia
(sedative effect)
-still have to give narcotic and
NSAID
-can cause sedation of the baby;
at higher concentrations and
prolonged administration can
cause neonatal apnea and
hypotension
Nitrous Oxide
-nonorganic inhalational anesthetic
- may cause uterine relaxation that
may lead to atony
Maternal Effects:
Low blood solubility renders
uptake and recovery vary
rapid
Low patency does not
provide complete analgesia
for delivery
Analegsic concentrations
(50-75%) does not cause
maternal cardiovascular or
respiratory depression and
does not affect uterine
contractibility
Neonatal Effects
Respiratory depression and
fetal acidosis
Nitrous Oxide - self-administered mixture
of 50-percent nitrous oxide (N2O) and
oxygen may provide satisfactory analgesia
during labor
- preparations: single cylinder (Entonox);
mixture of two gases from separate tanks
(Nitronox)
- gases are connected to a breathing circuit
through a valve that opens only when the
patient inspires
Halogen agents: Halothane,
Enflurane, Isoflurane, Sevoflurane
Maternal Effects:
Subanesthetic
concentrations provide
effective analgesia for
vaginl delivery
Fetal Effects:
Low concentrations over a
short period of time cause
neonatal sedation
Higher concentrations and
prolonged administrations
result in neonatal apnea and
hypotension
General Anesthesia
o Trained personnel and
specialized equipment (including
fiber-optic intubation) are
mandatory for the safe use of
general anesthesia.
o Common cause of death in
general anesthesia: failed
intubation
o Procedure:
1. Patient is rendered
unconscious Thiopental,
Ketamine
2. Muscle relaxant is given to
aid intubation
Succinylcholine (rapid- onset
and short-acting agent)
3. Sellick maneuver - Cricoid
pressure to occlude the
esophagus from the onset of
induction until intubation is
completed
4. Once the endotracheal tube
is secured, a 50:50 mixture
of nitrous oxide and oxygen
is administered to provide
analgesia.
o Usually, a volatile halogenated
agent (isoflurane, desflurane,
sevoflurane) is added to
 provide amnesia and
additional analgesia.
Upon completion of operation,
endotracheal 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
4. Local & Regional Anesthetic Techniques
Anesthetic Agents
o Some of the most common used
nerve block anesthetics, along with
their usual concentrations, doses,
and durations of action
o Onset, duration, and quality of
analgesia can be enhanced by
increasing the dose but can be done
safely on incremental administration
of small-bolus volumes
o Toxicity involves:
1. Central nervous system
toxicity
o early sympotms are those of
stimulation, but as serum
levels increase, depression
follows.
o Symptoms: may include
light-headedness, dizziness,
tinnitus, metallic taste, and
numbness of the tongue
and mouth. Patients may
show bizarre behavior,
slurred speech, muscle
fasciculation and excitation,
generalized convulsions,
followed by loss of
consciousness
2. Cardiovasuclar Toxicity
o develop later thatn the CNS and
they may not develop at all
because they are induced by
higher serum drug levels.
A. Peripheral Nerve Blocks (LOCAL)
1. Perineal infiltration
2. Pudendal block
3. Paracervical block
1. PERINEAL INFILTRATION
Most common local anesthetic
technique for vaginal delivery
o Inject at the sides of labia
majora
o during repair of episiotomy
site
o reference point is the ischial
spine, very vascular and
may cause vascular
congestion
Local anesthetic is injected into the
posterior fourchette
o Side effects:
1. Collapse of blood vessels
2. Cardiotoxicity most
dangerous, caused by mepivacaine
drug due to its affinity to cardiac
barriers may cause cardiac arrest
and cannot be resuscitated
Supplement unsatisfactory epidural
and pudendal blocks
o Use Lidocaine but
is not used for
spinal anesthesia
due to its transient
neurologic effect.
PARACERVICAL BLOCK
Injection of local anesthetic into the
paracervical nerve endings through
the vagina
Aim: block Frankenhausers
ganglion
Reference point 3 and 9 oclock
positions of cervix
Only provides pain relief in the 1 st
stage of labor
additional analgesia is required for
delivery because the pudendal
nerves are not blocked and the
anesthetics are short-acting
Pain relief in 5 minutes and lasts
for 45-60 minutes
Complications:
o associated with a high rate
(50%) of fetal bradycardia and
CNS medullary depression
(vascular collapse and apnea at
delivery) because of the close
proximity of the BV to the
paracervical area where you
inject your anesthesia
Fetal bradycardia can
cause fetal acidosis
Develops within 15 mins and
last up to 30 minutes
Possibility of fetal
trauma/infection
 olaceration
oinadvertent intravascular
injection -can cause systemic
toxicity; prevented by gradual
injection and frequent apiration
during injection
o parametrial hematoma
o abscess formation
o hypotension (maternal and fetal)
We dont use it anymore because it
can cause severe fatal tachycardia
Contraindicated in situations of
potential fetal compromise
Injection sites for anesthetics
3. PUDENDAL BLOCK
Provides adequate analgesia for
spontaneous delivery and outlet
forceps delivery
Injection of local anesthetic on both
sides of the vagina (10cc each
side)
Reference point ischial spines (do
IE)
Procedure:
Compute the dose according to
the weight of the patient; for
lidocaine: 3-5ml/kg BW
10 cm needle guided by fingers
(index or middle)
Injected on skin covering ischial
spines (at 3 and 9 oclock
positions) where the L and R
ganglia are located
Palpate fetal head to make sure
it is not accidentally hit by the
needle instead
When you inject, aspirate first,
then inject a portion (could be
1/3), then aspirate, then inject
another portion, do repeatedly
until entire volume is injected
Administered prior to delivery
-manipulation on the 2nd stage
of labor
Numbs the perianal area, vulva,
and the vagina
-numbed area enough for the
passage of the baby
Used frequently in labor and
delivery in combination with local
anesthesia
When you do pudendal block,
theres no need to do perineal
infiltration since it can cover up to
the perineum
Complications:
systemic toxicity
vaginal laceration -during IE
vaginal / ischiorectal hematoma
subgluteal abscess- if done in
nonsterile manner
Pudendal block can prolong the 2 nd
stage of labor
due to the loss of the bearing
down reflex of the patient because
the pain that is induced by the
passage of the baby to the
perineum is the reflex for the
mother to bear down
in other words: no pain > no reflex
> no bearing down > prolonged 2 nd
stage labor
Pudendal block
o does not provide adequate
analgesia when delivery requires
extensive obstetricalmanipulation.
o inadequate for women in whom
complete visualization of the cervix
and upper vagina or manual
exploration of the uterine cavity is
indicated
o Complications: systemic toxicity,
hematoma formation (when there
is coagulopathy), severe infection
at the injection site (may spread
posteriorly to the hip joint, gluteal
musculature, or the retropsoas
space) Dw wla na na mention ni ang pudendal
based sa audio pero gnbutang ko lng.