Obstetric anaesthesia and labour analgesia

Physiologic change during pregnancy &its implication/effect / influence/ on anaesthesia

1. Respiratory System
FRC -decrease 20%
tidal volume –increase 45%
respiratory rate –increase 15% The combination of deceased FRC and
increased oxygen consumption promotes rapid
residual volume – decrease 15%
oxygen desaturation during period of
expiratory reserve volume –decrease 20%
apnea/anesthesia
inspiratory reserve volume increase 5%
total lung capacity –decrease 5%
Minute ventilation – increase 45%
Blood gases
 Paco₂10 % decrease
 Pao₂=5-10% increase
 PH –no change
 Hcoȝ-decrease
 Oxygen consumption-increase 20%
2.Cardiovascular
Cardiac output-increase 50%
Stroke volume-increase 25%
Heart rate-increase 20%
Systemic vascular resistance –decrease 20%
Systolic blood pressure-decrease by 5%
Diastolic blood pressure-decrease by 15%
3. Haematology
Total blood volume –increase 45%
Plasma volume –increase 55%
Red cell volume-increase 25%
Haemoglobin decrease by 20%
Coagulation factors
• Factors VII, VIII, IX, X, XII, Fibrinogen- increase
• Factors XI,XIII- decrease
• Platelet count– no change or decrease
• Total protein ( albumin, globulin)- decrease
• -Hypercoagulable state-increased risk of thromboembolism

• 4. CNS
MAC- decrease by 30-40%
local anesthetic requirement- decrease by 30%
Gastrointestinal
Gastric emptying –decrease during labour, opioid
-no change during 1st-3rd trimester
-barrier pressure decrease

Renal
 GFR-increase 50%
 Renal plasma flow-increase 50%
Hepatic
• AST,ALT,LH,BILURIBIN-increase
• Alkaline phosphatase - increase
 Anesthetic implications
• 1.Respiratory system
Capillary engorgement of the respiratory mucosa, Upper airway edema, fluid retention
-large tongue-risk of trauma& difficult intubation- prepare smaller size cuffed tube 6,6.5
&Prepare option to manage difficult intubation( stylet, gum elastic bougie, LMA,
glidescope ,laryngoscope with different size of blade)
avoid nasal intubation-risk of epistaxis
Decrease FRC &increase oxygen consumption- risk of hypoxia during apnea/anesthesia,
intubation-need preoxigination with tight mask before intubation
.Once airway is secured ventilation should aimed to keep paco2 in the normal range of
pregnancy( avoid hyperventilation→hypocapnea →Alkalosis →uterine artery
vasoconstriction →↓placental blood flow→ neonatal asphyxia)
2. C.v.s
Aortocaval compression syndrome
Supine position-Lower abdominal Aorta compression with gravid uterus- decrease
uteroplacental blood flow-fetal hypoxia
Inferior venacava compression-decrease venous return to heart which decrease cardiac
out put-leading to Maternal hypotension
• Or supine hypotension /syndrome-associated with pallor, sweating, nausea and
vomiting
• Severe hypotension during regional or general anesthesia will lead to fetal hypoxia.
Management of aorto-caval
compression
• 1.left lateral decubitus
• 2.tilting the table to left side
• 3.rigid wedge under right hip
• 4. manual placement of uterus to left side
• Fluid preload during regional anesthesia
• C.N.S
a. Decrease csf protein – greater proportion of free &active drug
b. Elevated csf pH increases the unionized fraction of local anesthetic
c. Obstruction of inferior venacava with enlarge uterus cause
i. Distension/engorgement of epidural veins –decrease in lumbar csf volume,
subarachnoid space with enhancement of local anesthetic cephalad spread
&increased sensitivity to opioid, sedative &reduction of segmental local
anesthetic dose requirement for spinal anesthesia( decrease by 30%)
ii. decrease epidural space
iii. Increase epidural pressure
i&ii enhance cephalad spread of local anesthesia during regional anesthesia block
iii. Increased epidural pressure -Predispose to higher incidence of dural puncture
&intravascular injection during epidural anesthesia.
d. Lumbar lordosis contribute to cephalad spread of local anesthetic block
d. MAC –for inhalational anesthetic decrease by 40% during pregnancy-due to
endogenous B-endorphin& increased level of progesterone hormone
e. increased minute ventilation combined with decreased FRC& MAC -Rapid
induction with inhalational anesthetic
 GIT
• Increased progesterone- decrease gastro esophageal sphincter tone
• Placental gastrin- hypersecretion of gastric acid
• Gastric emptying –delayed with labor
• Upward and anterior displacement of the stomach by gravid uterus-
incompetence of gastro-esophageal sphincter-increase risk
gastroesophageal reflux &aspiration
• Narcotic &anticholinergic reduce lower esophageal sphincter
pressure
• For G/A ASPIRATION PROPHYLAXIX AND – RAPID SEQUENCE
INDUCTION & intubation with cuffed endotracheal tube WITH
SELLICK’S MANUEVER or cricoid pressure
• Extubation should be when the patient is awake and in side
position to reduce the chance of aspiration of gastric content.
RENAL CHANGE- ANESTHETIC IMPLICATION
• Increase GFR-Increased clearance of creatinine ,urea &uric acid
• -Decreased plasma concentration of BUN &creatinine
• -Marginally elevated bun &creatinine indicates severe renal impairment.
PREPARATION FOR ANESTHESIA 
• Preparation for anesthesia includes the administration of aspiration prophylaxis,
placement of one or more IV catheters, and standard American Society of
Anaesthesiologists monitors, preparation of equipment for difficult intubation
• Aspiration prophylaxis – The obstetric patient is at increased risk of aspiration of
gastric contents, especially in cases of difficult or failed intubation, when mask
ventilation may be required. worse outcome may be associated with aspiration of
particulate matter, acidic material, and of large volumes, goals for aspiration
prophylaxis are to eliminate particulate gastric contents and to decrease the volume
and acidity of stomach contents at the time of induction of anaesthesia.
• Pharmacologic prophylaxis – Administration of nonparticulate antacids, H2 receptor
antagonists, and/or metoclopramide should be considered before surgical
procedures
• Preoperative fasting – Gastric emptying is not changed by pregnancy and
preoperative fasting guidelines are the same for elective caesarean delivery as for
other surgical procedures (ie, two hour fast for clear liquids, six hours for solids, eight
hours for fatty meals
Labour analgesia
• PAIN PATHWAYS — Pain originates from different sites as
the process of labor and delivery progress
• The first stage of labor causes visceral pain, arising from
distention and ischemia of uterine and cervical tissues.
• Somatic pain occurs during the second stage or labor, as the
vagina, perineum, pelvic floor, and ligaments are stretched.
• 1.Neuraxial analgesic techniques (ie, epidural, spinal, and
combined spinal-epidural [CSE]) are the most effective
means of relieving the pain of labor and delivery
• Labour require blockade at T10-L1 in the first stage of
labour &T10-s4 in second stage of labour.
2. Opioids(Pethidine, fentanyl)
• Systemic opioids can provide some pain relief, with moderate
maternal satisfaction
• Mepiridine maximal maternal& fetal respiratory depression is
seen in 20-30 min following i.v administration.& in1-3 hour after
i.m administration. There fore it should not be administered
with in 3-4 hours of expected delivery
• Side effects: respiratory depression,sedation,plancental transfer
• 3. inhalational analgesic with 50% nitrous oxide plus with
oxygen
• 4. paracetamol intravenous analgesic
• 5. pudendal nerve block
 Anesthesia for cesarean section
• 1. General anesthesia
• 2. Regional anesthesia (spinal, epidural, combined spinal &epidural anesthesia(cse)
• A. General anesthesia
• Rapid sequence induction & intubation with cuffed endotracheal tube with cricoid
pressure
.General anesthetic drugs readily cross placenta& muscle relaxant do not cross
readily placenta
• Indication for general anesthesia
• 1.Emergency cesarean section-category I –imminent uterine rupture, fetal distress,
cord prolapse, severe fetal bradycardia
• 2.Failure of regional anesthesia
• 3.Maternal preference
• 4.Contraindication to regional anesthesia
• All intravenous and general anaesthetic pass through placenta
• Muscle relaxant cannot pass through placenta
Disadvantage of general
anesthesia
• Fetal depression by general anaesthetic rugs
• Difficult intubation
• Aspiration risk →chemical
pneumonitis( Mendelson's syndrome)
• Mathernal awareness during anaesthesia
• Inhalational anaesthetic cause uterine atony
resulting in haemorrhage
B. Regional anesthesia

• 1.Spinal anesthesia-most common choice

• Sensory block level for cesarean section –T4
• . A T4 level block is usually required for a cesarean section due to
traction on the peritoneum and uterine exteriorization
• Drugs for spinal anesthesia, epidural anesthesia
• Bupivacaine( Marcaine) =0.5% ( average dose 10-12.5mg)
• Combine with fentanyl 10-20ug or adrenaline 0.2mg
• Most common side effect of spinal anesthesia
• Hypotension-Treatment - phenylephrine, ephedrine
• Post spinal headache
Epidural , combined
epidural&spinal anesthesia
• Spinal anesthesia most common mode of anesthesia world wide
• Epidural catheter inserted during labor analgesia can be used to
give anesthesia& to control postoperative pain management.

Advantage of regional anesthesia

• 1. Avoid risk of difficult intubation
• 2. Avoid risk of aspiration of gastric content
• 3. Increase fetomaternal bond
• 4. No fetal depression like general anesthetic drugs
• 5. mother can contact baby earlier compared to general
Summary

• The hormonal changes that occur from very early on in pregnancy cause
a complex series of physiological and anatomical changes that affect
every system of the body. To illustrate how all these changes may alter or
affect anaesthetic management, it is useful to imagine performing a
general anaesthetic for caesarean section and list some key points:
• 1. Careful attention to the assessment of the airway and any necessary
preparation to deal with a potentially difficult airway in the pre operative
period.

• 2. When positioning the patient on the table, remember to use either a

left tilt of between 15 – 30 degrees on the table or a wedge under the
right buttock to minimize aorto-caval compression.
• 3. Venous access if often easier due to engorgement of
the venous system
• 4. Pre oxygenation is essential and should be with a tight
fitting mask for at least 3 minutes.
5. Rapid sequence induction with the application of
cricoid pressure is mandatory. Intubation may be difficult
and so adjuncts for difficult intubation should be
available. The trained anaesthetic assistant should be
careful when placing cricoid pressure if there is left tilt on
the operating table as the temptation is to place the
cricoid pressure straight down thus distorting the view at
laryngoscopy
• 6. Once the airway is secured, ventilation should be aimed to keep the PCO2 in the
normal range for pregnancy.

• 7. The MAC of volatile anaesthetic is reduced.

• 8. Volatile agents cause relaxation of the uterus (uterine atony) and may result in
haemorrhage after delivery of the fetus.

• 9. There is decreased sensitivity to endogenous and exogenous catecholamines

and so if vasopressors are required to maintain adequate blood pressure, the
amounts needed may be greater.

• 10. Extubation should be done with the patient awake and on their side to reduce
the risk of aspiration of gastric contents.