Anesthesia and Analgesia

in Obstetrics

Obstetric Analgesia
Non pharmacological method
(psychoprophylaxis, Transcutaneous
Electric Nerve Stimulation)
Systemic opioid analgesia
Inhalational agent (entonox)
Analgesia for vaginal delivery (local
infiltration, pudendal block, saddle block)
Patient Controlled Analgesia
Regional analgesia (spinal, epidural,
Combined Spinal Epidural analgesia)
GA for LSCS

Commonly used
sedatives/analgesics in labour
Opioid:
Pethidine (most common)
- Dose:50-100mg IM/IV at start of active
phase (cervix 4cm dilated)
- Delay gastric emptying, aspirationmetoclopramide/ promethazine
- Respiratory depression in neonate0.1mg/kg IV naloxone, bag and mask
ventilation

 Fentanyl -1mcg/kg IM/slow IV/infusion

- Cross placenta but not affect APGAR score
- Onset: 2-3min(IV), 10min(IM); last for 3060min
Tramadol 1-2mg/kg
Onset:15min; last for 2-3hr
Nalbuphine - 10mg IM/IV
Morphine 10mg IM

Inhalational agents
50:50 mixture of oxygen and nitrous oxide
(entonox)
- Analgesic at subanaesthetic conc., 5-6
breaths sufficient to provide analgesia during
a contraction (not interfere uterine
contraction& APGAR score)
- Through demand valve via mouthpiece/ face
mask & deliver a peak inspiratory flow of at
least 25L/min; deep breath before
contraction & stop when contraction over
- If conc persistent hyperventilation
decrease oxygen supply to fetus (however
gas elimination is fast, overall effect is small)

Regional analgesia- spinal/epidural

Bupivacaine 0.0625-0.125%; 0.5% for anaesthetic
Ropivacaine
Levobupivacaine
Bupivacaine + opioids(fentanyl 0.2mcg/mL)
LSCS: 2% lidocaine with epinephrine and 3%
chloroprocaine
- very high sensory to motor block ratio
- Opioid addition quicken the onset
- Analgesia maintenance: manual intermittent
boluses/ controlled infusion/ Patient Controlled
- Epidural bolus of 100mcg/mL local anaesthetic
can be of value in 2nd stage of labour

Non pharmacological
method
Psychoprophylaxis/ Lamaze
technique
Antenatal period:relaxation&
breathing exercise
Preparing the woman, allaying her
fear, distacting her from pain
Useful early in labour, questionable in
late labour

Transcutaneous Electrical Nerve

Stimulation (TENS)
Apply variable electrical stimulus to
skin at site of pain
Ideal for woman c/o blackache in
early stage of labour

NERVE SUPPLY OF FEMALE

GENITAL TRACT
Can be divided into external
genitalia and internal
genitalia

EXTERNAL GENITALIA
External genitalia is also known as
the vulva or pudendum
It includes the following: mons pubis,
labia majora, labia minora, hymen,
clitoris, vestibule, urethra, Skenes
glands, Bartholin glands and
vestibular glands.

 Boundaries:
1.)Anteriorly: Mons pubis
2.)Posteriorly: Rectum
3.)Laterally: Genitocrural fold

NERVE SUPPLY
Through bilateral spinal somatic nerves
Anterosuperior part:
1.)cutaneous branch of ilio ingunal
2.)genital branch of genito femoral
Posteroinferior part:
1.)pudendal branches of posterior cutaneus
nerve of thigh
Between these two groups,the vulva is
supplied by labial and perineal branches of
pudendal nerve.

INTERNAL GENITALIA

NERVE SUPPLY
Vagina: sympathetic and parasympathetic nerves
from pelvic plexus. The lower part is supplied by
pudendal nerve
Uterus: principally from sympathetic and partly
from parasympathetic.
- Sympathetic components are from T5 to T6 (motor)
and T10 to L1 spinal segments (sensory).The
abdomen area, supplied by T10 to L8 corresponds
to somatic distribution of uterine pain.
- The parasympathetic system is represented on
either side by the pelvic nerve which consists of
both motor and sensory fibres from S2,S3,S4 and
ends in ganglia of Frankenhauser.

 Fallopian tube:derived from ovarian

and uterine arteries
Ovaries:Sympathetic supply comes
down along the ovarian artery from
T10 segment

Epidural Analgesia
Provide lumbar and sacral analgesia
with minimal motor blockade.
Usually initiated at the onset of active
phase of labour. The patient will
appreciate a sense of giving birth
without pain during contractions
Beneficial in cases like PIH, breech
presentation, multiple gestations and
preterm labour

Contraindications
Maternal coagulopathy or on
anticoagulant therapy
Supine hypotension
Hypovolemia
Neurological diseases
Spinal deformity
Skin infection at injection site

Technique
1. Patient lies on her side and her back
is aseptically prepared.
2. A needle is used to create a lumbar
puncture at L1, L2 into the epidural
space.
3. A plastic catheter is passed via a
needle and kept in there, taped to
the back for continued analgesia.
Bupivocaine 0.125% + fentanyl
0.2g/ml is recommended.

Complications
Slow onset of analgesia
Patchy analgesia if solution does not spread
evenly in the epidural space
Bloody tap or convulsions due to injecting
anesthetics into vessels.
Dural puncture causing post puncture
headaches.
Maternal hypotension can cause
uteroplacental insufficiency and fetal
distress

Analgesia for Vaginal

Delivery
Pudendal Block
Saddle block

Pudendal block:
Used for perineal analgesia
Normally combined with a perineal
and vulval infiltration of local
anaesthetic to block ilioinguinal and
genital branch of genitofemoral
nerve

Indication:
Analgesia for the second
stage of labor
Repair of an episiotomy
or perineal laceration
Outlet instrument
delivery (to assist with
pelvic floor relaxation)
Used in the past as an
alternative to neuroaxial
analgesia in assisted
twin and breech
deliveries
Minor surgeries of the
lower vagina and
perineum

Contraindication:
Patient refusal
Patient's inability to
cooperate
Patient sensitivity to
local anesthetics
Presence of infection
in the ischiorectal
space or the
adjacent structures,
including the vagina
or perineum
Coagulation
disorders

Technique: Vaginal route

Perineal route
Vaginal route
1. A trumpet is used to guide a 15cm,17-20
gauge spinal needle with a 20mL syringe
containing 1% lignocaine into the ischial spine
2. Vagina is pierced at ischial spine and a little
further to encroach into sacrospinous ligament
3. 10mL lignocaine is injected after making sure
to exclude a vascular entry
4. Pudendal nerve, as it winds around ischial
spine is now anaesthetised
5. Same procedure is repeated on the other side

Perineal Route
1. Going through perineum at ischial
tuberosity and guiding the needle
just beyond ischial spine, 10mL of
1% lignocaine is injected.
2. Procedure is repeated on the other
side

 Along with pudendal block, perineal and vulvar

infiltration is performed to block ilioinguinal and
genital branch of genitofemoral nerve
Perineal infiltration:
For episiotomy
Perineum infiltrated with 10mL 1% xylocaine in
fanwise manner starting from middle fourchette
For outlet forceps
Needle inserted just posterior to introitus
about 10 mL of 1% xylocaine infiltrated in fanwise
manner on both side of midline
Needle then directed anteriorly along each side of
vulva as far as anterior third to block genital brach of
genitofemoral and ilioinguinal nerve.
5mL required to block each side

Saddle block:
Low spinal anaesthesia confined
to vagina and perineum
Spinal puncture is between L2-L5
with the patient in sitting position
5% solution of lignocaine is used
Patient remain in sitting position
for 5 more minutes to facilitate
drug to get fixed in lower nerve
root
Useful in midcavity forceps and for
repair of perineal or vaginal tear
after delivery

General Anaesthesia
Indications:
1. Extreme emergency eg: cord prolapse,acute fetal distress,severe
haemorrhage
2. Maternal coagulopathy which negates a regional anaesthesia eg: HELLP
syndrome, idiopathic thrombocytopenic purpura,abruptio placenta)
3. Anterior placenta previa with prior caesarean anticipating an adherent
placenta,torrential haemorrhage and extensive surgery
4. Cardiac disease like severe MS,AS,cyanotic congenital heart disease
where regional anaesthesia will cause changes in afterload
5. Anatomic problems ,making regional anaesthesia difficult like severe
kyphoscoliosis,spina bifida
6. Internal podalic version and breech extraction
7. Maternal request

Technique:
1. 100% 02 is administered by tight fit mask for >3minutes
2. Induction by injection of thioentone sodium 200-250mg
(4mg/kg) as 2.5% solution IV, followed by refrigerated
suxamethonium 100mg
3. Assistant apply cricoid pressure as consciousness is lost
4. Patient is intubated with cuffed endotracheal tube and
cuff is inflated
5. Maintainance 50% N02 ,50% 02 and a trace of halothane
6. Relaxation maintained by nondepolarising muscle
relaxant
7. After delivery of baby, N02 increased to 70% and
narcotics injected IV to supplement anaesthesia

Complications:
1. Mendelson syndrome
Aspiration of gastric content due to
delayed gastric emptying ( high level of
serum progesterone, decreased motilin
and maternal apprehension during labour)
Aspiration of gastric acid contents with
development of chemical pneumonitis,
atelectasis and bronchopneumonia
c/f: tachycardia, tachypnea,
bronchospasm,ronchi,cyanosis,hypotensio
n

Px:
- Patient should not be allowed during
labour
- H2 blocker(Ranitidine 150mg orally)
should be given night before and to be
repeated (50mg IM/IV) 1 hour before
administration of general anesthetic
too increase gastric pH
-Metoclopramide (10mg IV) given after
min 3 minutes of preoygenation to
decrease gastric volume and increase
tone of lower esophageal sphincter

Px:
- Non particulate antacid (0.3 molar
sodium citrate 30mL) given orally
before transferring patient to theatre
to neutralize exusting gastric acid
- Intubation with adequate cricoid
pressure following induction should be
done
-Awake extubation should be routine

Mx:
- Immediate suctioning of oropharynx
and nasopharynxto remove inhaled
matter
-Bronchoscopy is needed if there is any
particulate matter
-Continuous positive pressure
ventilation to maintain arterial 02
saturation of 95%
-Antibiotic administered when infection
is evident

Complications:
2. Bronchospasm and atelectasis(due to
aspiration)
3. Blood loss due to uterine relaxation
due caused by some inhalational
agents
4. Slower post op recovery
5.Failed intubation
6.Baby more acidotic

Spinal Anesthesia
Injection of local anesthetic agent into
subarachnoid space.
Used in alleviating pain of delivery and
during 3rd stage of labour.
Advantages:
i. Minimal risk of atonic PPH
ii. No neonatal depression
iii. Dangers of aspiration are less
iv. Safe

Technique
1. Informed consent is taken. Patients
and fetals vitals are continuously
monitored.
2. Patient assumes a seated or lateral
decubitus position.
3. Identify the area for access (line
from the top of both iliac crests,
which coincides with the L3-L4
interspace) and clean it with
antiseptic and drape.

4. Intradermal and subQ local anesthetic

injection is given.
5. Insert the needle, directed midline or
paramedian (midline is preferred to
reduce lumbar lordorsis) until loss of
resistance is felt.
6. Remove the stylet and CSF should drip
out.
7. Inject hyperbaric bupivocaine (10-12 mg)
or 50-70 mg lignocaine.
8. Replace the stylet and remove the needle
and wait for 5-10 minutes for the
anesthesis to be complete and fixed.

Complications
Hypotension due to blocking of
sympathetic fibres vasodilation
and low CO
Respiratory depression/paralysis due
to high spinal block
Failed block, chemical meningitis,
epidural abscess
Postspinal headache due to CSF
leakage

Epidural Anesthesia
Although epidural analgesia is ideal for
labour analgesia, epidural anesthesia is
not as popular but has a definite role in
C-sec of severe preeclampsia.
Advantages: can be topped up if an
epidural was already in place and patient
lands up in an emergency C-section
Common drugs used are 2% lignocaine
with epinephrine or 3% chloroprocaine.

Combined Spinal Epidural

Anesthesia
Combined advantages of rapid onset of
analgesia after spinal and able to continue
analgesia for prolonged time with epidural.
Advantages:
1. Access to top up an inadequate spinal
2. Top up to an adequate spinal if surgery
gets prolonged
3. Good post-op anesthesia through epidural
catheter.

Local Anesthesia
In rare cases of severe coagulation failure
with renal failure, other forms of anesthesia
may be harmful.
A field block of the ant. abdominal wall is
done towards the ant. edge of 8 th 11th ribs
B/L, with additional infiltration over incision
site.
Each layer is slowly anesthetised before
incision is made.
2% lignocaine is used.

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