Definition

Uterine stimulants (uterotonics) are medications that cause, or increase the frequency and intensity of, uterine contractions. These drugs are used to induce (start) or augment (stimulate) labor, facilitate uterine contractions following a miscarriage, induce abortion, or reduce hemorrhage following childbirth or abortion. The three uterotonics used most frequently are oxytocins, prostaglandins, and ergots. Depending upon the type of drug, uterotonics may be given intravenously ( !), intramuscularly ( "), as a vaginal gel or suppository, or in oral form.

Purpose
Uterine stimulants are used to induce, or begin, labor in certain circumstances when the mother has not begun labor naturally. These circumstances may include if the mother is post#dates, that is, gestation that is over $% wee&s'especially if tests indicate a decrease in amniotic fluid volume. They may be used in cases of premature rupture of the membranes, preeclampsia (elevated blood pressure in the late stage of pregnancy), diabetes, and intra#uterine growth retardation ( U()) when these conditions require delivery before labor has begun. They may be recommended if the expectant mother lives a great distance from the healthcare facility and there is concern for either her or her baby*s safety if she were unable to reach the facility once labor begins. They are also used in the augmentation of existing contractions to increase strength and frequency when labor is not progressing well. +ccording to the +merican ,ollege of -bstetrics and (ynecology (+,-(), the .//%s saw an increase in the rate of induced labor' from /0 to .10. n a "ay 2., 3%%., statement, the +,-( reported that the increase in the cesarian rate seen over the same period of time was not due to the induction process but to other factors, such as the condition of the cervix at the time of induction and whether or not the pregnancy was the woman*s first. -xytocin and prostaglandin (4() are naturally occurring hormones used to induce labor. They are also available in synthetic form (4itocin and 5yntocinon are the synthetic counterparts of oxytocin). 4( is also used to ripen the cervix prior to induction, which is sometimes sufficient to stimulate labor, and the woman needs no further medication for labor to progress. There are many forms of 4(s, but those of greatest interest are 4(6., 4(63, and 4(73 alpha. )esearch is investigating which are the most effective for which process. 7or example, 4(63 in the form of dinoprostone (,ervidil and 4repidil) has proven superior to the 4(7 series in cervical ripening. "isoprostol (,ytotec), a synthetic 4(6., also is effective in cervical ripening and labor induction, while the 4(73 alpha analog, carboprost (4rostin .8#", or 9emabate), is the preferred 4( uterine stimulant. The ergots, which significantly increase uterine

activity, have severe side effects in many women. -nly one ergot, methylergonovine maleate ("ethergine) is now used in the United 5tates, and is used only to control postpartum hemorrhage (449). -xytocin is also used in a contraction stress test (,5T). This is done prior to the onset of labor to evaluate the fetus*s ability to handle uterine contractions. To avoid the possibility of exogenous (introduced) oxytocin putting the woman into labor, she may instead be as&ed to stimulate her nipples to cause the release of natural oxytocin. + negative, or normal, test is one in which there are three contractions in a .%#minute period, with no abnormal slowing of the fetal heart rate (79)). 7alse positives of the ,5T do occur, however. +lso, the expectant mother should remain in the health care setting for about half an hour after a negative test to ma&e sure the test did not stimulate labor. f a woman has a miscarriage, oxytocin may be used to bring on contractions to assure that all the products of conception (4-,) are expelled from the uterus. f the fetus died but was not expelled, prostaglandin (4(63) may be used to ripen the cervix to facilitate a dilatation and evacuation, and:or to encourage more uterine contractions. n this case, prostaglandin may be used either in gel form or as a vaginal suppository. n a routine delivery oxytocin may be ordered after the placenta has been delivered in order to increase uterine contractions and minimi;e bleeding. -xytocin (4itocin) also may be used to treat uterine hemorrhage. <hile hemorrhage occurs in about $0 of vaginal deliveries and =0 of cesarian deliveries, it accounts for about 280 of maternal deaths due to bleeding during pregnancy. The role of oxytocin is to bring on and strengthen uterine contractions. f the hemorrhage stems from the placental detachment site, contractions help to close off the blood vessels and thereby stop the excessive bleeding. +dditional medications may be used, including 4(73 alpha (9emabate), misoprostol (,ytotec), or the ergot methylergonovine ("ethergine). f the uterus is contracted but bleeding continues, the cause may be retained placenta, genital tract laceration, or uterine rupture. >arge clots that remain in the lower part of the uterus can inhibit the uterus from contracting, leading to uterine atony (lac& of tone or tension), a leading cause of postpartum hemorrhage. Uterine contractions also help to expel large clots and placental fragments.

Precautions
t is important to establish a clear baseline of vital signs before a woman is given any medication to induce labor. ,onsistent reevaluation and documentation of vital signs allow for faster recognition of an abnormal change in a woman*s condition. +lso, a clear labor and delivery record will assist the postpartum nurse in monitoring for changes as well. Documentation includes time and dosage of any medications given, as well as any side effects that might occur. 4roper documentation will help avoid the chance of medication

doses being given too close together. +n increasing pulse and a decreasing blood pressure signal a potential hemorrhage. <hen oxytocin is given !, it must be diluted in ! fluid and never given as a straight !. 4(s should not be given if there is any question about fetal well#being, for example, an abnormal 79) tracing. The ergot, "ethergine, should never be given via ! and never to a woman with hypertension.

Description
Oxytocin -xytocin*s ma?or functions are in labor and lactation. n vitro, production and secretion of oxytocin is stimulated by the pituitary gland. @ust what happens to initiate labor remains a mystery, even although much research has focused on this area. The hormone estrogen appears to increase the number of oxytocin receptors as the gestation period increases. The degree to which uterine muscles are sensitive to oxytocin*s action appears lin&ed to the number of oxytocin receptors. -xytocin levels increase as labor progresses, and the fetus also secretes oxytocin during labor, increasing the amount of circulating oxytocin. n a normally progressing labor, contractions become more frequent, more intense, and last longer. n a dysfunctional labor, contractions may wea&en, become further apart, or even stop. + prolonged labor puts the mother at ris& of fatigue, which can increase the li&eli#hood of a cesarian delivery or fetal distress. -xytocin may be given to augment the labor. 5ome women may need only a very small amount in order to A?ump startA labor once again. 7or others it may be necessary to continue the oxytocin in small increments. -xytocin increases the strength, duration, and frequency of contractions, so care must be ta&en to prevent the contractions from becoming too strong or too frequent. f the mother has an infection, labor may not progress as usual. -xytocin is less effective in such cases. Baturally occurring oxytocin plays a role in breast#feeding by facilitating both mil& e?ection and the letdown reflex. <hen the neonate suc&les at the breast, the nipple stimulation sends a message to the pituitary gland to release oxytocin. -xytocin then causes the mil& gland cells to constrict, pushing the mil& forward towards the nipples. Creastfeeding immediately after delivery encourages oxytocin production and causes uterine contractions, helping the uterus to become firm and close off the blood vessels at the placental detachment site. This process limits the amount of blood lost after childbirth. Cecause the release of oxytocin is inhibited by fear, pain, embarrassment, and distraction, providing the new mother with a calm environment in which she can focus on her infant will facilitate breastfeeding and the production of oxytocin.

Prostaglandins 4rostaglandins play a ma?or role in the stimulation of uterine contractions that begin the labor process. )esearch indicates that 4(s also facilitate the mother*s transition between phases of the labor process. 5ome 4(s promote vasoconstriction while others promote vasodilation. -ne function of 4(s is to promote cervical effacement and dilation during labor. -xytocin plays a role in stimulating the release of 4(s. nfection stimulates their release, also, which appears to be a factor in the initiation of up to 2%0 of cases of preterm labor. 4(s serve a function in immunosuppression, but the exact mechanism is unclear. They also may be a ma?or factor in regulating umbilical blood flow by &eeping the ductus arteriosus open during fetal life. Ergots 6rgots are produced by a fungus that forms primarily on rye grain. Cecause of its potentially harmful side effects, one form (6rgonovine, or 6rgotrate) was ta&en off the mar&et in .//2 and methylergonovine maleate ("ethergine) is now the only form used, and is used only as a uterine stimulant to control 449. (There is no evidence that "ethergine used as a prophylactic decreases the ris& of 449.) 6ven so, because of the complications it can cause, and because its use is contraindicated in a large number of women, "ethergine has been replaced by the 4(s as the second#line uterotonic of choice.

Preparation
Cefore any procedure is begun or medication administered, it is important for the nurse to review the information with the pregnant woman to ensure she understands what will ta&e place and the potential side effects of the medication. +ny allergies to medication need to be reviewed, as well as any prior response the mother may have had to the medications. The mother may be anxious about induction or augmentation, fearing that the contractions will come too fast or that she will feel out of control of the process. The nurse needs to address her concerns, as well as those of her partner.

Aftercare
,lose supervision of the mother during induction or cervical ripening must ta&e place. The 79) and uterine contractions are usually monitored for an hour after induction. 7requent chec&s of vital signs alert the nurse to any potential complications.

Complications

Oxytocin The effect of ! oxytocin is rapid following administration. The individual response to oxytocin can vary considerably and administration is usually increased slowly and incrementally. 9yperstimulation of the uterus, which can result from oxytocin augmentation, can place the fetus at ris& for asphyxia. 9yperstimulation is defined as more than five contractions in .% minutes, contractions lasting longer than =% seconds, and increased uterine tonus either with or without significant decrease in 79). Uterine rupture has also been lin&ed to oxytocin administration, particularly for periods longer than four hours. -xytocin has a small antidiuretic effect that is usually dose related and that can lead to water intoxication (hyponatremia). -nset occurs gradually and may go unnoticed. 5igns may include reduced urine output, confusion, nausea, convulsions, and coma. "others receiving oxytocin need to have their blood pressure monitored closely, as both hypotension and hypertension can occur, and'although the sub?ect remains controversial'evidence suggests oxytocin increases the incidence of neonatal jaundice. +lthough oxytocin may put women with a classical cesarian section scar from a prior delivery at increased ris& of uterine rupture, contraindications to the use of the drug are virtually the same as contraindications for labor. -ther side effects of oxytocin include nausea, vomiting, cardiac arrhythmias, and fetal bradycardia. <hen used ?udiciously oxytocin is a very effective medication for the progression of labor. Prostaglandins 5ignificant systemic side effects are associated with the use of 4(s. These include headache, nausea, diarrhea, tachycardia, vomiting, chills, fever, sweating, hypertension, and hypotension. There is also increased incidence of uterine hyperstimulation and potential for uterine rupture. 4(73 alpha (carboprost'4rostin .8#" or 9emabate) can cause hypotension, pulmonary edema, and'in women with asthma'intense bronchospasms. Cecause it stimulates the production of steroids, carboprost may be contraindicated in women with adrenal gland disease. <hen used for abortion it may result in sufficient blood loss to cause anemia, necessitating a transfusion. "edical problems (or history) of diabetes, epilepsy, heart or blood vessel disease, jaundice, &idney disease, or liver disease should be brought to the attention of the health care practitioner before the use of carboprost. +lso, in rare instances, ophthalmic pressure has increased in women with glaucoma with the use of this 4(. Ergots 6rgots have an alpha adrenergic action with a vasoconstricive effect. They can cause hypertension, cardiovascular changes, cyanosis, muscle pain, tingling, other symptoms associated with decreased blood circulation, and severe uterine cramping. The health care professional should be well aware of other medications being ta&en by the patientD the presence or history of medical problems such as

angina, hypertension, stro&e, infection, &idney and liver disease, and )aynaud*s phenomenon may be contraindications to the use of this drug.

KEY TER !
Atony' n uterine atony, the uterus fails to contract after delivery, remaining relaxed. This flaccid condition can lead to hemorrhage, and puts the mother at ris& of shoc& and death. Augment'Drugs to augment labor are given after labor has begun, but fails to progress, or when the contractions have slowed down and are wea& or ineffective, prolonging labor unnecessarily. "emorrhage'The loss of an excessive amount of blood in a short period of time. +fter childbirth, a loss of more than 8%% m> over a 3$#hour period is considered postpartal hemorrhage. The blood loss may be sudden and swift, or slow and continuous. #nduce$ induction'To begin or start. Post%dates'(estation longer than approximately $% wee&s. Up to $3 wee&s may still be still considered normal.

Results
+nticipated outcomes for uterine stimulants are either to prepare the cervix for childbirth, induce or stimulate uterine contractions to produce a safe delivery of a newborn, encourage a complete spontaneous or induced abortion, eliminate blood clots or other 4-, debris from the uterus, and decrease or stop hemorrhage following childbirth or abortion. Bormal results would meet these outcomes without significant side effects'either for the mother or, in the case of childbirth, the infant.

"eath care team roles

Burses play a ma?or role in preparing the patient for, and administering, uterine stimulants and monitoring the patient and fetus during the labor process. Cecause the choice of drug, its form of administration, and its side effects varies, &nowledge of uterine physiology is an important aspect of caring for women and their fetuses undergoing treatment with these drugs. Burses must be aware of potential complications and side effects, as well as dosing requirements, criteria assessment, and contraindications to these drugs. They should ta&e a complete medical history of the patient, including prescription and over#the#counter medications, illnesses, and disease. n most instances a gynecologist or other qualified physician will perform the actual delivery, although this may occasionally be facilitated by a midwife. + pediatrician or family health care practitioner will examine the newborn infant and administer treatment if required. The nurse can be an important source of information and comfort to women facing induction of labor or abortion, and to new mothers facing the initial responsibility of parenthood.

The Effect of
&isher$ David E)

aternal Anesthetic and Analgesic Drugs on the &etus and 'e(born

D* Paton$ +ohn ,) D

Alliance for the #mprovement of

aternity !ervices -A# !.

)eturn to 9ome 4age

/,!TETR#C DR01!2 T"E#R E&&ECT! /'

/T"ER A'D #'&A'T

"ost women assume that the drugs offered them by their obstetricians during pregnancy, labor, birth and lactation have been approved by the U.5. 7ood and Drug +dministration as safe for use under those condition. The fact is, there is no maternally administered drug that has been proven safe for the fetus. Bor is there any law or regulation that prohibits a physician from prescribing or administered to a childbearing woman a drug that has never been approved by the 7D+ as safe for such use. #'"ERE'T R#!K! /& /,!TETR#C RE3ATED DR01! 5eldom do their obstetricians advise pregnant women that an unborn baby*s central nervous system is rapidly forming throughout the latter months of pregnancy, childbirth and the first two years of life, and during that time the central nervous system is susceptible to permanent damage from drugs prescribed for or administered to the pregnant woman. ,hanges in the placenta as pregnancy advances heighten the transfer to the fetal circulation of all drugs used in obstetric analgesia and anesthesia. +s the time of birth grows near the fetal brain is relatively large and the cerebral blood flow is high in comparison to the adult brain. n addition, the myelin content of the brain, the fat#li&e substance which protects the nerve fibers of the brain, is low when compared to the adult. The baby*s brain and central nervous system, therefore, are relatively more vulnerable to drugs administered to or ta&en by the mother during the perinatal period and during lactation. (estational age, previous and concomitant exposure to other drugs, relative hypoxia and various pathological conditions can affect how a drug given to the mother will affect her unborn or newborn infant. The brain and heart of an about#to#be#born or newly born infant is vessel#rich. 9ypoxemia (low levels of oxygen of the blood) and a resulting build up of lactic acid in the fetal blood during labor and birth can increase the upta&e by the fetal brain and heart of drugs given to the mother. 5everal studies have shown that drugs administered to the mother alter fetal brain function. <hether this dysfunction has implications for the child*s future central nervous system development has not been the sub?ect of a well#controlled scientific investigation. Cut many respected scientists are beginning to express their concern that drugs administered with the very best

of intentions to the pregnant woman near or at term may limit the exposed offspring*s ability to achieve his or her full potential in life. "others#to#be are sometimes cautioned by their obstetrician or anesthesiologist that experiencing pain during labor can decrease the oxygen supply to the fetus. This may ma&e the physician feel more noble but, in fact, 'o research has shown this to be true in the human fetus. Drugs trapped in the infant*s brain at birth have the potential to affect adversely the rapidly developing nerve circuity of the brain and central nervous system by altering the following brain processesE a. The rate at which the nerve cells in the brain mature b. The process by which the brain cells develop individual characteristics and capacity to carry out specific functions c. The process by which the brain cells are guided into their proper place within the brain and central nervous system. d. The interconnection of the branch#li&e nerve fibers as the circuitry of the brain is formed, and e. The forming of the insulating sheath of myelin (fat#li&e substance) around the nerve fibers which helps to assure that the nerve impulses # the messages to and from the brain # will travel their normal route at the normal rate of speed. Dr. @oseph +ltman, neurobiologist, University of ndiana, pointed out at a <ashington ,onference on the 4recursor of >earning Disability that the development of the human brain appears to be programmed so that certain cells and nerve fibers must develop in synchrony, in order to ma&e appropriate connections within the central nervous system. 9e expressed concern that drug#induced alterations of the chemical components within the brain may interfere with the growth of the cells and nerve fibers, causing subtle or substantial misconnections within the developing brain. To better understand this hypothesis, picture a technician preparing to connect hundreds of wires. The ends of each wire are color#coded, to serve as a guide as to which wire should be connected with another. + chemical is spilled over the wires, removing the color. To meet his schedule the technician must continue to connect the wires, unable to be sure which wire to connect to another.The ?ob is finished on schedule, the system functions, but functions imperfectly. +ny alteration in the development of the intricately complex nerve circuitry of the brain has the potential for permanently altering the way the brain processes and responds to information. 9ow much an individual fetus or newborn infant will be

affected by a drug administered to the mother during pregnancy, childbirth or lactation is unpredictable. (enetic susceptibility, which affects the final outcome, varies greatly, even among siblings. <ell#controlled experiments in animals, for example, often produce varying results in the test animals, even among litter mates. "ost physicians and pharmaceutical manufacturers are quic& to say that there is no drug on the mar&et that is without ris&. Bone of the drugs or chemicals used as medications or food additives, or in shampoo, hair coloring, underarm deodorants and s&in treatments, and the li&e, have been sub?ected to a well#controlled scientific investigation to determine what effect the drug or chemical has on the fetus. That doesn*t mean that all of these drugs and chemicals are harmful. t ?ust means that we do not &now if there are any adverse effects on the fetus and newborn. &DA !TAT0! /& DR01! The United 5tates 7ood and Drug +dministration (7D+) never approves a drug for general or AuniversalA use, but only for specific indications and conditions. -nly if the words ApregnancyA, AobstetricsA, AlaborA, AdeliveryA, or AlactationA appear in the 4#'D#CAT#/'!4 section of the drug*s pac&age insert, (the 7D+#approved information leaflet included in each carton of an approved drug) has the 7D+ approved the use of the drug for those conditions. f the conditions described above are discussed elsewhere in the pac&age insert but are not specifically noted in the 4#'D#CAT#/'!4 section, the drug has not been approved by the 7D+ for such uses. f the pac&age insert ma&es no mention that the use of the drug is contraindicated in pregnancy, labor, delivery, or lactation one cannot assume that the drug is safe to be used at those times.The 7D+, in general, does not require drug manufacturers to list contraindications to the use of a drug in the pac&age insert. &DA APPR/5ED DR01! #' /,!TETR#C! Two drugs approved by the 7D+ for use during pregnancy, are a combination of doxcylamine and pyridoxine (Cendectin) and ritodrine (Futopar). -nce prescribed as a remedy for morning sic&ness, Cendectin was ta&en off the mar&et in ./12 because of the high cost of defending the company against law suits. 5everal lawsuits have been brought against the manufacturer of Cendectin by parents who contend that their children*s birth defects resulted from prenatal exposure to the drug. ,urrently the litigation is lumbering through the courts with both sides claiming victories. Bo one &nows how many cases have been settled out of court, since in most such cases the plaintiffs must swear to secrecy in order to receive the settlement.

The only other drug specifically approved by the 7D+ for use during pregnancy is ritodrine (Futapar), a neurotransmitter prescribed or administered to pregnant women in order to halt preterm labor.+nother drug, terbutaline, is also administered for the same purpose. 9owever, the drug has not been approved by the 7D+ for that use. Until fairly recently some tranquili;ers, such as dia;epam (!alium), were frequently administered to women during labor to alleviate their anxiety. Cecause of their adverse effects on the newborn infant the 7D+ no longer approves these drugs for such use. Cut as mentioned earlier, lac& of 7D+ approval does not mean that your doctor is prohibited from prescribing a tranquili;er for you during labor. A'A31E!#C! The most frequently used drug in labor is a narcotic#li&e analgesic called meperidine, Demerol (4ethidine in the UG). The use of meperidine has largely replaced the use of morphine during labor. This drug is frequently offered to the laboring woman by the obstetrician, nurse or midwife, accompanied by the standard remar&, AThis will help to ta&e the edge off the contractions.A "eperidine does not eradicate pain, but for many women it ma&es the discomfort or pain of the contractions more tolerable. -ther women find that meperidine causes them to lose control of their labor. "eperidine is usually administered by in?ection either intramuscularly ( ") or intravenously ( !) in doses of 8% mg repeated every four hours, if the health care provider so desires and the mother agrees. +s with most pain relieving drugs, meperidine can slow maternal respiration and circulation.<hen a narcoti;ed mother breathes more slowly than normal and her blood flows more slowly than normal through her lung tissue there is always the li&elihood that the fetus will receive less than a normal supply of oxygen. n a well#controlled investigation by @ohn "orrison, an obstetrician at the University of "ississippi, one of every .% infants of mothers who received only 8% mg of meperidine during labor required resuscitation at birth. 7or this within . to 2 hours before delivery required resuscitation at birth.Unfortunately, it is difficult to insure that the baby will be born at a time when the effect of meperidine is minimal. 7or this reason midwives often administer the drug in smaller doses. such as 38 mg or .3 mg (or none at all) in order to insure that the mother will feel in control of her labor and the baby will be ready to breathe on his own immediately after birth. +fter repeated administrations of the drug, even in smaller doses, meperidine and its metabolite normeperidine tend to accumulate in the fetal circulation. "eperidine is not without side effects, such asE sweating, di;;iness, headache, nausea, vomiting, slowing of gastric function, agitation, tremor, uncoordinated muscle movement, transient hallucinations and disorientation, and visual disturbance.

The more serious ha;ards of meperidine for the mother are respiratory depression, respiratory arrest, circulatory depression, shoc&, cardiac arrest, coma and death. + less well &nown fact about meperidine is that the drug can cause an increase in cerebral spinal fluid pressure. The implications of this effect on mother, fetus and newborn infant, however, have not been investigated. <e have no way of &nowing how frequently these adverse effects occur under normal clinical conditions because the law does not require physicians or midwives to report adverse drug reactions to the 7D+, even if the patient dies. The 7D+ has allowed the manufacturers of meperidine to provide in the drug*s pac&age insert only a minimum of information in regard to the drug*s adverse effects on the fetus and newborn infant. The insert ac&nowledges that the drug crosses the placenta and can depress the respiratory and the psychophysiologic functions of the newborn infant and can increase the li&elihood that the newborn infant may require resuscitation. The insert does not ma&e clear that meperidine given to the mother during labor can slow the fetal heart and impede the normal transfer of oxygen from the mother*s circulation to that of her fetus. 5evere or prolonged oxygen depletion has been shown to cause the fetal brain to swell. <hether an increase in cerebral spinal fluid pressure in the presense of fetal hypoxia, ruptured membranes and:or forceps extraction increases the li&elihood of permanent brain dysfunction has yet to be investigated. There is some concern that the severely narcoti;ed newborn infant may be more prone to aspirate (inhale its gastric fluids) because the drug has blunted or paraly;ed his protective gag reflex. -ther narcotic#li&e drugs approved by the 7D+ for use in labor are nalbuphine (Bubain), butorphanol (5tadol) and alphaprodine (Bisentil). -ther drugs, namely hydromorphone (Dilaudid), fentanyl citrate (5ublima;e), and codeine, are also used in labor, but the 7D+ has not approved them for such use. >i&e meperidine, the delayed or long#term effects of drugs given during labor on the exposed fetus have not been adequately investigated. The little research that has been done on Bubain has shown the drug to concentrate more in the fetal circulation than in the mother*s. Cutorphanol is forty times more powerful than meperidine and must be administered with extreme care to avoid an overdose. 9ydroxy;ine (!istaril) is an antianxiety, antinausea drug sometimes administered to women during labor. The potentiating action of hydroxy;ine must be considered when the drug is used in con?unction with other drugs which depress the central nervous system. 'ARC/T#C A'TA1/'#!T Baloxone (Barcan) has been approved by the 7D+ for use in infants narcoti;ed by drugs administered to the mother, but the 7D+ has not approved the use of naloxone during labor. n most cases the sluggish, drugged infant becomes alert after

receiving naloxone. 9owever, once the short#acting naloxone has worn off, those infants given naloxone show no improvement over those infants who did not receive the drug. The infant receiving naloxone must be carefully and continuously observed because if the naloxone wears off before the effects of the meperidine have dissipated the baby could be ?eopardy. Baloxone should not be administered to a depressed infant unless the infant is narcoti;ed. f the newborn infant is hypoxic for reasons other than being narcoti;ed naloxone can actually deepen the hypoxic state of the infant. A'T#E ET#C! "eperidine is often administered in con?unction with a drug called prometha;ine (4henergan) or in a combination called "epergan. 4rometha;ine relieves the nausea and vomiting caused by the administration of meperidine or other powerful pain relievers. 4rometha;ine is thought to potentiate the effects of meperidine, allowing less of the latter drug to be used. The drug is not without ris&, however. )esearch has shown that prometha;ine can mar&edly impair platelet aggregation in the fetus and newborn, a condition that can cause bleeding within the brain of the fetus and newborn without a similar effect in the mother. A'TAC#D! Bausea and vomiting are common maternal side effects of the powerful pain relieving drugs administered during labor. n an attempt to minimi;e the possibility of chemical pneumonia, which can occur if the heavily drugged or anestheti;ed mother vomits and aspirates the fluids or food from her stomach, women have been given various antacids during labor to reduce the acidity of the stomach*s contents. This is done in the belief that, should the mother regurgitate in response to anesthesia, she is less li&ely to suffer chemical pneumonia. +ntacids may improve the odds of a safe outcome but they can not be relied upon to prevent maternal mortality from aspiration. f aspiration occurs following the administration of an antacid, particles in the antacid itself can cause substantial maternal morbidity. +lthough the 7D+ has not approved the drug for such use, a systemic antacid, sodium citrate and citric acid (Cicitra), is frequently administered to women during labor. The drug does cross the placenta and enter the fetus and its delayed, long term effects on the exposed offspring have not been investigated. +s with other antacids, the drug has not been approved by the 7D+ for use in obstetric care. RE1#/'A3 A'E!T"E!#A2

Drugs most commonly used in regional anesthesia to bloc& pain impulses are bupivacaine ("arcaine, 5ensorcaine), lidocaine (Hylocaine), mepivacaine (,arbocaine) and chloroprocaine (Besacaine). Depending on the area to be anestheti;ed, they are administered as an epidural, spinal, caudal, saddle, or pudendal bloc&, or as a local infiltration for episiotomy repair. The once popular paracervical bloc& has been abandoned in most obstetric services because of its adverse effects on the fetus. 6pidural, spinal and caudal anesthesia numb the woman from above her navel to her toes. +ll regional anesthetics reach the fetal circulation and, consequently, the fetal brain within seconds or minutes of administration to the mother. 6ach of these drugs has its own inherent ris&s. Cecause a health care provider is not required to report an adverse drug effect to the 7D+, there is no way of &nowing the exact incidence of such effects. 4erhaps the text of the pac&age insert of bupivacaine is the best example of potential problems. The pac&age insert reads in partE A>ocal anesthetics rapidly cross the placenta, and when used for epidural, caudal or pudendal bloc& anesthesia, can cause varying degrees of maternal, fetal and neonatal toxicity.The incidence and degree of toxicity depend upon the procedure performed, the type and amount of drug used, and the technique of drug administration. +dverse reactions in the parturient, fetus and neonate involve alteration of the central nervous system, peripheral vascular tone, and cardiac function......A ABeurologic effects following epidural or caudal anesthesia may include spinal bloc& of varying magnitude (including high or total spinal bloc&)D hypotension secondary to spinal bloc&D urinary retentionD fecal and urinary incontinenceD loss of perineal sensation and sexual functionD persistent anesthesiaD paresthesia, wea&ness, paralysis of the lower extremities, and loss of sphincter control, all of which may have slow, incomplete or no recoveryD headacheD bac&acheD septic meningitisD meningismusD slowing of laborD increased incidence of forceps deliveryD cranial nerve palsies due to traction on nerves from loss of cerebrospinal fluid.A <ide experience with the use of epidural bloc&s also indicates that epidural bloc& (in?ection into the space between the spinal column and the dural membrane enveloping the spinal cord) is associated with significantly longer labors, more use of oxytocin (Apit dripA), rotational forceps deliveries and mar&edly more postpartum bladder catheteri;ation. t is well accepted that an episiotomy is almost unavoidable if regional anesthesia is in effect during delivery because the epidural bloc& causes the mother to lose her ability to bear down effectively, unduly prolonging the expulsion of the baby. 4icture !P#'A3 "EADAC"E

The severe headache that some mothers experience for days, wee&s, even months, after having an epidural or spinal bloc& is more li&ely to be due to the lea&age of cerebral spinal fluid from the in?ection site than from the anesthetic itself.<hile a blood patch can be administered to stop the lea&age, there is no guarantee that it will be successful in quelling the headache. The pac&age insert for regional anesthetics provide little information as to the effect of the drugs on the immediate neurologic development of the exposed offspring and none on the delayed, long term effects. Deborah )osenblatt and her colleagues at 5t. "ary*s 9ospital in >ondon found correlations between epidural anesthesia in childbirth and certain neurologic effects in the exposed offspring that persisted throughout a six wee& testing period. "ore recent research by 5ep&os&i et. al. supports the findings of )osenblatt et. al. )esearch by Thorp and colleagues has shown a .% fold increase in the rate od cesarean section where first time mothers have an epidural bloc& during labor "ost obstetricians quietly agree that epidural bloc& also increases the rate of cesarean section. +n epidural bloc& causes the pelvic musculature to become flaccid or limp. Therefore, the AtroughA of pelvic muscles which normally rotates the baby into the proper position to move efficiently through the birth process dysfunctions. P0DE'DA3 ,3/CK "others who experience a drug free birth often comment that, one of the most rewarding sensations of giving birth is the feeling of power as they ease their babies out into the world. Fet, well meaning obstetricians frequently ta&e away this gratifying moment by administering a pudendal bloc& to numb the mother*s perineum ?ust as she is about to give birth. + pudendal bloc& is performed by in?ecting an anesthetic drug through the vagina into the pudendal nerve on either side of the vagina. The irony of this misguided &indness is that it can indirectly cause the mother*s perineum to rupture. <hyI Cecause the pudendal bloc& blunts or obliterates the burning sensation which normally occurs as the baby*s head distends the mother*s perineum. This warning sensation, when intact, warns the mother to bear down with ?ust enough force to ease her baby out but not enough to rupture her perineum. The anesthetic used in a pudendal bloc& reaches the infant*s circulation in seconds or minutes and has the potential for having the same neurological effect on the fetus as an epidural in?ection of the same drug. 5ince a pudendal bloc& is relatively short lived, an additional anesthetic is usually administered to numb the perineum if sutures are required to repair an episiotomy or a rupture in the perineum. 1E'ERA3 A'E!T"E!#A

(eneral anesthesia is seldom used for vaginal birth today in the United 5tates. t is used, however, for cesarean section if a rapid delivery is needed or if the mother is bleeding. t may also be used if there is a need or desire to provide absence of sensation and consciousness. Typically, for general anesthesia an induction anesthetic such as thiopental (4entothal) is given by in?ection, rapidly followed by an in?ection of succinylcholine (+nectine). + few seconds later the mother drifts into unconsciousness, and pressure is applied to the cricoid cartilage, ?ust below the larynx, to prevent aspiration while a laryngoscope is inserted into the mother*s trachea. +n endotracheal tube is inserted through the laryngoscope, and the cuff of the endotracheal tube is inflated to seal any space in the mother*s trachea that the tube does not fill. The anesthetist or anesthesiologist listens to the mother*s lungs with a stethoscope to be certain the endotracheal tube is in her airway and not in her esophagus.-nce the seal is assured anesthesia is maintained with nitrous oxide and oxygen. + low concentration of a volatile agent such as halothane (7luothane) is also given to provide amnesia. The endotracheal tube must not be removed until the mother is able to follow commands. +s with any type of anesthesia, general anesthesia must be given s&illfully. +lthough women are often told not to eat if they thin& they may be in labor, there is no documented case of aspiration in a woman who was properly anestheti;ed, whether or not she ate. The combination of nitrous oxide and oxygen can also be given by mas& as analgesia, but it is seldom used in the United 5tates. 5edatives and hypnotics such as barbiturates (5econal, >uminal, Bembutal), chloral hydrate, and flura;epam (Dalmane) may sometimes be used in early labor, but the 7D+ has not approved their use in pregnancy or labor. These drugs may cause respiratory depression in the newborn. <hether or not exposure to analgesic drugs during labor and birth contributes to the high rate of subtle difficulties in learning and behavior in children has yet to be adequately investigated. 0TER#'E !T# 03A'T! -xytocin (4itocin, 5yntocinon) is a powerful synthetic hormone administered to women in order to initiate and:or to stimulate labor. The drug is frequently the physician*s preferred method of stimulating contractions and speeding up labor, even though it is well &nown that helping the mother to wal&, stand or sit during labor reduces the discomfort of contraction and facilitates the normal progress of labor in the ma?ority of women. -xytocin is frequently necessary when epidural bloc& alters the normal progress of labor.

The 7D+ has approved the use of oxytocin in labor and delivery when medically indicated) 4rostaglandin gel is also administered in some hospitals as a uterine stimulant or cervical AsoftenerA, but the 7D+ has not approved prostaglandin for such use. The use of oxytocin in obstetrics, even if necessary, is not without ris&. f the mother*s membranes have ruptured the augmentation of contractions can adversely affect the fetal brain by increasing compression of the fetal s&ull, increasing intracranial pressure, increasing the possibility of tears in the cerebral membranes, and by inhibiting the normal transfer of oxygen from the mother*s circulatory system to the fetal brain. During a normal contraction the maternal blood vessels which carry oxygenated blood through the uterine wall to the placenta are constricted. During these periods of diminished blood flow the oxygen in the mother*s blood, which stores up in the placenta*s intervillous space between contractions maintains the fetal brain with a relatively constant supply of oxygen. Uterine stimulants which foreshorten these oxygen#replenishing intervals, by ma&ing the contractions too long, too strong, or too close together, increase the li&elihood that brain cells will die. The situation is somewhat analogous to holding an infant under the surface of the water, allowing the infant to come to the surface to gasp for air, but not to breathe. Critish scientific investigators have noted that the use of oxytocin to induce labor increases the incidence of ?aundice in the newborn. <hether the frequent use of oxytocin in the United 5tates to stimulate labor contributes to the high incidence of ?aundice in the newborn period has yet to be investigated. +ll of us would li&e to be able to provide the laboring woman with a magic remedy that would ta&e away her pain, leave her with all her senses intact, and would be free of harm to her and her baby. 5uch a drug is not yet at hand. 7or now, each mother (and father as well) must be given the facts and allowed to ma&e their own decision as to what is right for them and their baby. J3%%% D-) 5 C. 9+ )6 6ffect of analgesia on labour )honda Coyle The effect of analgesia on the stress of labourE The pain of labour and delivery involves local segmental, suprasegmental and cortical stress responses. 4roperly administered analgesia ma&es labour safer. )espiration. 6pidural analgesia prevents transient hyperventilation during, and hypoventilation between, uterine contractions, so that maternal 4a,-3 remains 31#23mm9g and 4a-3 about .%%mm9g (.). The incidence of hypoxaemia during first or second stage labour is 2 times greater with no analgesia, or ..$ times greater with intramuscular pethidine, than when epidural analgesia is provided by

bupivacaine %..380 without fentanyl (3) (,hapter 1K). "aternal hypoxia during labour has not correlated with non reassuring cardiotocography . 5ome studies have (2) and others ($, 8) have not correlated maternal hypoxia with low neonatal +pgar scores (Table 28..) or abnormal umbilical cord blood gases. )educed Beuroendocrine 6ffects of 4ain The relief of pain and associated anxiety with continuous epidural analgesia reduces maternal catecholamine, beta endorphins, +,T9 and cortisol. (=, K, 1, /) Total wor& of labour, maternal metabolism and oxygen consumption are reduced. "aternal and fetal acidosis are reduced (.%) though active pushing during second stage sustains some metabolic acidosis whether or not epidural analgesia is administered. )educed ,ardiovascular 6ffects of 4ain 6pidural analgesia eliminates the increase in cardiac output, heart rate and blood pressure caused by pain. Uterine +ctivity ,atecholamine alpha receptor stimulation causes uterine hypertonus, and beta receptor stimulation decreases uterine tone and contractility. 6pidural analgesia without adrenaline may (a) reduce effect of circulating catecholamines causing uterine hypo and hyper activity, and (b) change incoordinate uterine activity to a normal labour pattern. +llowing an epidural to wear off during second stage increases circulating catecholamines, leading to impairment of uterine activity and a longer second stage. (..) 6ffect of analgesia on duration of 3nd stage of labour and mode of delivery 5tudies of the effects of epidural analgesia can be classified into those in which a particular epidural drug or administration .. 5lows labour, increasing the rate of instrumental deliveries (.3, .2, .$, .8, .=, .K, .1, ./) or has no effect (.$, 3%, 3., 33, 32, 3$, 38, 3=), and 3. mproves the progress of labour (.., 33, 38, 3K, 31, 3/) <hy do studies give conflicting results I There are many unanswered questions with regard to effects of epidural analgesia on second stage of labour and mode of delivery. <hen designing a study, particular attention should be paid to the following areasE .. 4atient matchingE 4atients studied are not always comparable to controls in proportion of primigravidae : multigravidae, age, pre#existing medical or obstetric complication, maternal height, fetal si;e. <hen groups not receiving epidurals are compared with those undergoing epidural

analgesia, the process of randomi;ation should occur before analgesia is requested. 3. ,onduct of labourE >abours are not always comparable to controls. -nset of labour before or after 2K wee&s, duration of active stage, posture of mother during second stage (2%), timing and dose of oxytocin, prostacyclin, rupture of membranes all affect duration of second stage. 5imilar definitions are required between study and control groups of beginning of second stage (full cervical dilatation, or appearance at introitus of presenting part). 2. -bstetric "anagementE The extent of labour monitoring, indications for augmentation and rates of instrumental and operative delivery are sometimes not specified or are not supervised by someone other than the provider of epidural analgesia. $. +naesthetic managementE +naesthetic end#points and outcomes are not always consistent. nvestigators should report the incidence of spontaneous vaginal delivery, quality of analgesia in both first and second stage, degree of motor bloc&, rate of perineal trauma (2.) and extent of maternal expulsive efforts. 5tudies do not always specify adverse effects on gastric emptying, fetal acidosis or respiratory depression. +mong a large group of patients with a uniform sensory level, epidural analgesia will have different effects on labour haemodynamics. 8. 5tatistical powerE The si;e of groups may not be large enough to detect significant differences (23). The mechanisms of prolongation of labour by epidural analgesiaE . 5omatic motor bloc&ade increases dystocia. )emoval of the urge to push and perineal muscle relaxation may slow internal rotation and descent of the fetal head. +. The use of dilute concentrations of local anaesthesia with:without opioids provides less motor bloc&ade. C. 5ome local anaesthetics (,hapter $) preferentially bloc& motor over sensory fibres (,hapter 11) (22). ,. -pioids alone (epidural or parenteral) reduce somatic bloc& but provide inadequate maternal analgesia, increase gastric stasis and fetal depression. 6pidural opioids increase duration of active phase of stage . (2$). D. 6pidural clonidine and fentanyl, when used alone, preserve motor function but analgesia is inadequate (28). 6. 4redictably, intrathecal bupivacaine in addition to or instead of, epidural bupivacaine reduces the required dose for labour analgesia but does not reduce the degree of motor bloc&ade or the duration of the second stage (2=). . 6pidural bloc&ade of pelvic autonomic nerves may abolish the increment in oxytocin levels that occurs normally between full cervical dilatation and crowning of the fetal head (2K). -xytocin is claimed to be crucial to correct rotation and descent of fetal head

but does not correlate with uterine contractility or spontaneous delivery. 4lasma oxytocin levels have questionable clinical significance (21). . +ortocaval compression, not epidural bloc&ade, reduces uterine perfusion and contractility even in the absence of demonstrable hypotension (2/). !. f the intravenous fluid load prior to an epidural is administered as a bolus, rather than at a maintenance infusion rate, a 3% minute decrease in uterine activity results (33). The bolus transiently inhibits posterior pituitary production of antidiuretic hormone and perhaps of oxytocin. !. "edico legal climate ($%). >egal notions regarding the appropriate duration of the various stages of labour may influence obstetric management. ! . +n arbitrary time limit, not maternal or fetal well being, may be used to terminate labour and ?ustify operative delivery. ! . 6pidurals ($.) account for only 1.20 of total variability in the duration of second stage of labour. K80 of variability in the length of second stage cannot be accounted for (7igure 22.2). t is no wonder that an improvement in spontaneous delivery rate has not been shown despite absence of motor bloc& in ma?ority of parturients (23, $3, $2, $$). <hile the need for instrumental vaginal delivery will decline as motor power is retained, this effect can exert only a minor influence until all other factors influencing second stage duration are better understood. 5ummary >abour is unpredictable and influenced by many factors. +naesthetic technique can affect the course of fetal descent and delivery but ?udicious obstetric and anaesthetic management provide safe maternal and fetal care without excessive prolongation of labour 6pidural analgesia and the progress of labour >eonie <atterson 6pidural analgesia has become an established technique in the management of severe labour pain. "any feel that its use, however, has been implicated in prolonging the duration of labour and in increasing the incidence of fetal malposition. Coth of these events have been associated with an increased instrumental delivery rate as a result of fetal distress (Table 2..) and maternal exhaustion or because accepted limits for the duration of second stage have been exceeded. The association between instrumental delivery and perinatal

morbidity has been responsible for a reluctance to employ epidurals in high ris& deliveries (eg. twin gestations and breech presentations) (7igure .$..) (., 3). 5everal mechanisms have been proposed to explain the association of epidural analgesia with instrumental delivery. These mechanisms generally become manifest in the second stage of labour (from full dilatation of the cervix to delivery) and includeE .. bloc&ade of the motor units of sacral nerves resulting from local anaesthetic agents administered during the first stage of labour. This effect may be cumulative and persist into the second stage (2). The resulting wea&ness of pelvic floor muscles reduces the effectiveness of maternal pushing and the involuntary bearing down reflexD 3. bloc&ade of sensory fibres disrupting the coordination between maternal pushing and uterine contractionsD 2. diminution of a neuro#endocrine reflex, in which distension of the vaginal wall causes an augmented secretion of oxytocin from the posterior pituitary. 6vidence to support this includes an observed reduction in the force of uterine contractions and oxytocin levels during second stage of labour during epidural analgesia ($, 8)D $. depression of uterine contractility by adrenaline#containing local anaesthetic solutions by a direct effect similar to that of beta# agonist tocolytic agents used to inhibit premature labour (=). n contrast to the above, there is evidence to show that epidural analgesia may accelerate an already prolonged and exhausting labour and reduce the need for delivery by caesarean section for failure to progress. The provision of effective analgesia reduces the inhibitory effect of endogenous maternal catecholamines on uterine contractility, attenuates the maternal acidosis and permits the mother to tolerate augmentation with oxytocin (K, 1, /) (,hapter 22). 6vidence in the literature does not consistently support either view. ,larification of the issue has been difficult for a number of reasonsE .. <hilst the collective experience is great, the techniques used to achieve epidural analgesia over the last four decades have not been uniform. 7or example, the techniques vary in choice of agent, drug concentration, administration during the second stage and addition of an opioid. -ver the same period of time, obstetric practice has evolved. 4rolongation of the second stage beyond 3 hours in the absence of fetal distress is no longer an indication for forceps delivery (.%). The definition of *forceps delivery* has been revised to distinguish between true mid#cavity and low forceps (..). + tendency to avoid forceps delivery in favour of caesarean section has

lowered the rate of instrumental delivery independent of anaesthetic practice (.3). 7inally, the inability to control for institutional or individual practice persists. 3. "any of the studies to date have been criticised for bias because allocation to the analgesic groups has been determined by maternal request for epidural analgesia rather than true randomi;ation (.2). 7or example, a parturient with a minor degree of cephalo#pelvic disproportion or occipito#posterior presentation is more li&ely to experience severe pain and therefore more li&ely to request epidural analgesia. 5uch patients are also more li&ely to require instrumental delivery. Two studies have attempted to eliminate this bias, one by randomi;ing study groups (.2), the other by restricting the study group to those with occipito#anterior presentations (.$). n both of these studies, epidural analgesia was associated with an increased instrumental delivery rate. 2. 6arly reports describing the association between instrumental delivery and poor neonatal outcome failed to differentiate between the different instrumental techniques used. t is now recognised that mid#cavity, rotational forceps deliveries are strongly associated with increased perinatal mortality whereas there is no such association with the use of low# and outlet#forceps, or !entouse vacuum extraction. Despite these difficulties, three firm conclusions can be drawn about the effects of epidural analgesia on the progress of labourE .. -verall, epidurals *per se* are associated with an increased incidence of instrumental deliveries but progressively more dilute concentrations of local anaesthetic agents reduce this increased incidence. The dose#sparing effect of opioid#local anaesthetic combinations further adds to this reduction. 3. 6pidurals are associated with a prolongation of the second stage of labour. This is not associated with neonatal morbidity in an properly managed labour. 2. >ow (as opposed to high) concentration local anaesthetic solutions appear to reduce the increased incidence of mid#cavity rotation forceps delivery. The arguments for these conclusions are expanded belowE .. 4rogressively more dilute concentrations of local anaesthetic agents reduce the increased incidence of instrumental deliveries observed with epidurals.

The increasing trend towards the use of bupivacaine in low concentrations reflects a perception that in doing so there will be less motor bloc& and that there will be maximisation of its property of differential sensory bloc&ade thus providing analgesia without motor bloc&ade, a lower instrumental delivery rate, and greater maternal satisfaction (.8). This has been borne out by the observation that %.80 bupivacaine is associated with high rates of malposition (2 times control rate) and forceps delivery (8 times control rate) (.=). <hile a progressive reduction from a high concentration has been associated with a reduction in instrumental deliveries (2, .K, ./), the experience with bupivacaine %.380 (.$, 3%, 3., 33, 32, 3$) and %..380 (.2) has not clearly demonstrated a decreased instrumental delivery rate. n contrast, studies using very low concentration solutions of both bupivacaine %.%=380 (38) and lignocaine %.K80 (3=) have shown that epidural analgesia may be continued throughout the second stage without an increase in the instrumental delivery rate. n the case of lignocaine %.%K80, this has been associated with less effective analgesia (3=). The addition of epidural opioids to local anaesthetic solutions appears to improve the analgesic efficacy of low dose bupivacaine regimens which hitherto had demonstrated a reduction in the forceps delivery rate, but which were limited by high failure rates with respect to pain relief (38, 3=, 3K, 23). The combination of bupivacaine %.%=380 with fentanyl %.%%30 has been shown to decrease the higher instrument rate which is observed when bupivacaine %..380 is used alone whilst maintaining the same quality of analgesia (3K). This is consistent with the dose sparing effect of opioids described in other series (22, 2$, 28, 2=, 2K) (7igure .%3..) (,hapter =%). There is further support for the practice of minimi;ing motor bloc&ade and preserving involuntary expulsive efforts by reducing the amount of local anaesthetic which reaches sacral segments of the spinal cord. This support is derived from studies which demonstrate a reduced forceps rate as a result of practicing segmental epidural bloc&ade. This technique involves positioning the tip of the epidural catheter near the T.. # T.3 segments during the first stage of labour, thereby avoiding the progressive effects of local anaesthesia on pelvic muscle tone. <hen full cervical dilation has been achieved, it may be repositioned to include sacral segments during second stage (K, 31, 3/, 2%). )opivacaine may be further able to reduce instrumental delivery rate. The practice of discontinuing the epidural when the cervix is fully dilated is widespread in labour wards. t should be appreciated that this will not reliably eliminate the effects of first stage epidural analgesia. 5everal studies have described persistent perineal anaesthesia after saline was blindly substituted for epidural solution during second stage. The forceps rate is not reliably reduced. This

may reflect progressive motor wea&ness occurring during first stage (33). "oreover, the percentage of women reporting inadequate analgesia is clearly increased ( 3., 33, 3=, 2.). 3. 6pidurals are associated with a prolongation of the second stage of labour. The effect of epidural analgesia on the duration of labour has been studied in many series. +s with the mode of delivery, results are inconsistent. n general, there appears to be no clear effect on the duration of the first stage (1, 33). The second stage is more consistently prolonged in both primiparous and multiparous women (1, .2, 2/, 3/, $%), but this prolongation appears to be less mar&ed when dilute solutions are used (.K, 3=, 33, 3K). 5everal authors have argued that a prolonged second stage is not associated with fetal heart rate abnormalities, low +pgar scores (Table 28..), or low umbilical cord p9s, as long as electronic fetal heart rate monitoring is employed, and maternal analgesia and hydration are maintained (.2, $%, $., $3). n addition, there is support for observation of a latent period in early second stage to allow descent of the head before pushing is commenced, as opposed to pushing from the time of cervical dilatation. t has been argued that the instrumental delivery rate can be reduced by the acceptance of a longer second stage (3$, $%, $3, $2). 2. >ow concentration local anaesthetic solutions appear to reduce the incidence of mid#cavity rotation forceps delivery. The increased perinatal mortality rate associated with instrumental delivery is largely attributable to intracranial hemorrhage or birth asphyxia and is often associated with the use of mid#cavity, rotational (eg. Giellands) forceps (., 3). 4remature infants are at particular ris& as are term infants in the presence of undiagnosed cephalo#pelvic disproportion. n contrast, morbidity associated with low forceps or ventouse, vacuum extraction appears to be confined to facial bruising and cephalohaematoma, respectively ($$). >ow concentration local anaesthetic solutions can reduce the forceps delivery rate ($2). The equivocal results obtained for %.380 bupivacaine are of interestE a high incidence of mid#cavity forceps deliveries in some series (.$, 3%), low forceps or vacuum extractions in others (3.) or no observed increase in instrumental deliveries in others still (33, 32, 3$). 5imilarly, %..380 bupivacaine has not reliably demonstrated a non#increased instrument rate (.2, .K). 9owever, a high incidence of mid#cavity forceps deliveries is not apparent, with instrumental deliveries largely representing low forceps or vacuum extractions.

6pidural Technique ,live ,ollier .. 7ollowing placement of secure venous access, and the infusion of at least 8%% ml of a crystalloid solution, the patient is positioned on her left side with nec& flexed and &nees drawn up as far as possible (,hapter $$). 5ome operators prefer the sitting position, particularly for the obese parturient (,hapter .%8). 3. + appropriate vasopressor, such as ephedrine, should be close at hand (,hapter K/). +n aseptic technique should be adhered to. + midline or paramedian approach may be used. 2. 7or the midline approach, the s&in and underlying tissues are infiltrated with local anaesthetic in the midline at the mid#point of either the >3 # >2 or >2 # >$ interspace. (The spinal cord ends at >2 or above in at least /K0 of the population (7igure .=..)). The bony and ligamentous structures of the region are shown in 7igure 6.3. +n epidural (Tuohy) needle is inserted in the sagittal plane, with its bevel pointing cephalad. +fter traversing the supraspinous ligament, the needle is then passed into the interspinous ligament which grips it tightly. The stylet is removed from the Tuohy needle and the loss#of#resistance syringe attached. The syringe may contain saline, air or both according to preference. The Tuohy needle may then be advanced slowly using either a continuous or intermittent movement. >oss#of#resistance is detected by applying gentle pressure to the plunger of the syringe (7igure 6.2). <hen the needle is in the ligamentum flavum, increased resistance is transmitted to the plunger, only to disappear when the epidural space has been entered (,hapter 23). $. 7or the paramedian approach, local anaesthetic is infiltrated .8mm lateral to the cephalad end (upper border) of the vertebral spinous process below the selected interspace. The Tuohy needle is inserted at /%% to all s&in planes. The paravertebral muscles are penetrated until the bone of the vertebral lamina is encountered. The depth of needle insertion is noted. The needle is partially withdrawn and redirected cephalad and towards the midline until the previous depth is attained. -nce the ligament is entered, the syringe is attached and the needle is slowly advanced while searching for loss#of#resistance. 8. <hichever approach has been used, the depth to which the needle has been inserted is noted. 7ollowing negative aspiration for blood or ,57, a small volume of local anaesthetic (2#$ ml) may be in?ected into the epidural space to aid the subsequent catheter insertion. The catheter is advanced 2#$cms (7igure 6.8)beyond the previously#noted distance between the s&in and epidural space. f too much catheter is threaded into the epidural space, it may emerge through an intervertebral foramen causing failure of the epidural.

=. The Tuohy needle is gently removed and the catheter is fixed to the s&in under a transparent adhesive dressing. + test dose (,hapter /.) of local anaesthetic is given through the catheter before the main dose is administered in increments (,hapter =%). K. Use of a continuous catheter is generally preferable to a single#shot technique to cover most obstetric eventualities. The +ustralian and Bew Lealand ,ollege of +naesthetists has outlined the requirements for the safe conduct of epidural analgesia (4.$). Preamble 6pidural analgesia is a safe and effective method of pain relief in labour, provided appropriate precautions are ta&en as followsE .. 6pidural puncture and:or cannulation of the epidural space should be carried out only by persons with adequate training and experience in the technique. 3. 5uch persons must beE 3.. readily availableto supervise the subsequent management of the epidural 3.3 competent to deal with the occasional life threatening and other complications which may arise following the in?ection of agents into the epidural or sub#arachnoid space. 2. +n appropriately trained person must be present to assist the anaesthetist whilst performing the epidural bloc&. $. -nce epidural analgesia has been established, and the response of the patient to the agent or agents has been assessed by the anaesthetist, further doses to maintain analgesia may be administered by other suitably trained medical or nursing staff, provided thatE $.. The dose has been prescribed by the anaesthetistD $.3 The anaesthetist deleating the Atop#upA procedure is satisfied that the person who will carry out the tas& is competent to do so and competent to appropriately monitor the patient and her fetusD

$.2 The person carrying out these tas&s is satisfied that he or she is competent to do soD $.$ +ppropriate equipment and s&illed staff are readily availableto treat complications and any adverse reactionsD and $.8 <ritten instructions and management guidelines are provided.

8. +ll patients undergoing epidural analgesia must be nursed in an area appropriately equipped with staff able toE 8.. monitor both the patient and fetusD 8.3 detect the extent of the bloc& and any adverse effectsD and 8.2 ?udge the necessity for top#up doses. =. + record must be made of the procedure, the clinical and other observations and the instructions deleated to the attending staff. K. +ll patients receiving epidural analgesia must have an intravenous infusion commenced before the institution of the bloc& and the infusion must be let in situ for the duration of the bloc&. 1. 5atisfactory and safe epidural analgesia can be produced by continuous or patient#controlled epidural infusion of local anaesthetic alone, opioid alone or local anaesthetic#opioid mixtures. The same principle of management should apply when epidural analgesia is administered by any of these methods. /. <hen there is no further need for the epidural, the catheter should be removed by the anaesthetist or other suitably trained medical or nursing staff. .%. +t all times the ultimate responsibility for the management of epidural analgesia remains that of the anaesthetist who performs the procedure or a deleated suitably trained registered medical practitioner.

... +ll patients having epidural analgesia in labour must be admitted under the direct care and supervision of a registered medical practitioner. The vertebral levels which correspond to important landmar&s within the spinal canal. n 20 of the population the cord ends at >. or above. n /$0 of the population the cord ends at >. or >3. n 20 of the poulation the cord ends at >2. "odified and re#drawn fromE *>umbar 4uncture and 5pinal +nalgesia*. ). "acintosh. Clac&wells Coo&s, -xford.

+ meta#analysis of the sub?ect has been recently published by 9alpern et al. ($8). )eferencesE .. -*Driscoll G, "eagher DD Traumatic intracranial haemorrhage in firstborn infants and delivery with obstetric forceps. Critish @ournal of -bstetrics and (ynaecology, 11E=, @une ./1K. 8KK#8K/.

3. ,hiswic& ">, @ames DGD Gielland*s forcepsE association with neonatal morbidity and mortality . Critish "edical @ournal, =th @an, ./K/. K#/. 2. Thorburn @, "oir DDD 6xtradural analgesiaE the influence of volume and concentration of bupivacaine on the mode of delivery, analgesic efficacy, and motor bloc&. Cr.@. +naesth. ./1.D 82E/22 $. Cates )(, 9elm ,<D Uterine activity in the second stage of labour and the effect of epidural analgesia. Critish @ournal of -bstetrics and (ynaecology, Dec ./18, /3 .3$=#.38%. 8. "atadial >, ,ibils >D The effect of epidural analgesia on uterine activity and blood pressure. +m. @. -bstet. (ynecol., @uly ./K=, .38E= 1$=#18$. =. >ederman )4, >ederman 6, <or& C, "c,ann D5E +nxiety and epinephrine in multiparous women in labourE )elationship to duration of labour and fetal heart pattern. +m @. -bstet (yaecol. Dec .8th, ./18 .82E1 1K%#1KK. K. "altau @", +ndersen 9TD 6pidural anaesthesia as an alternative to caesarean section in the treatment of prolonged, exhaustive labour. +cta +naesth. 5cand. ./K8 ./D 2$/#28$.

1eneral Anaesthesia in /bstetrics Clive Collier

There remain very few obstetric situations where general anaesthesia ((+) is essential. The ma?ority of patients undergoing general anaesthesia will have refused or been unsuitable for a regional technique, or there may have been insufficient time for insertion of a bloc& in the emergency situation. The incidence of usage of the various techniques of anaesthesia for caesarean section in a modern obstetric hospital is shown in 7igure K2... Urgent general anaesthesia may be requested for breech extraction or to provide uterine relaxation for intrauterine manipulation, particularly of a second twin, although intravenous glyceryl trinitrate is a possible alternative in this situation (,hapter 83). (+ will usually be preferred for emergency ,aesarean section following uterine rupture, antepartum haemorrhage, placental abruption (Table 6.2), acute fetal distress (Table 2..) or cord prolapse. (+ may also be requested in the presence of intra#uterine fetal death. <hile lesser degrees of placenta praevia can be satisfactorily managed under regional bloc&, the method of anaesthesia for a grade !

placenta praevia remains controversial. "any anaesthetists fear the combination of massive maternal haemorrhage and impairment of cardiovascular reflexes in an awa&e patient. (eneral anaesthesia may also be administered for removal of a cervical suture prior to labour, manual removal of the placenta or products of conception, treatment of an acute inversion of the uterus and repair of a third degree tear. + suggested sequence for elective ,aesarean section (+ followsE # +BT+, D5E )anitidine 2%%mg orally (or cimetidine $%%mg orally), 1 hours and 3 hours prior to induction, and:or %.2 "olar sodium citrate solution 2%ml orally 2% minutes preoperatively. # 7+5T B(E for = to 1 hours. # 4-5 T -BE >eft lateral tilt on a wedge under the right hip. # "-B T-) B(E 4ulse oximetry, 6,(, blood pressure, capnography, oxygen analysis, inspiratory pressure monitoring, peripheral nerve stimulation. # 9FD)+T -BE +n intravenous crystalloid solution delivered through a .$ or .= gauge cannula. # 4)6-HF(6B+T -BE <ith .%%0 oxygen for 2 minutes. # BDU,T -BE )apid sequence with cricoid pressure using thiopentone $ to 8mg:&g, followed by suxamethonium ..% to ..8 mg:&g prior to intubation with a cuffed endotracheal tube. # "+ BT6B+B,6E 7resh gas flow of 1 litres:min with oxygen 8%0 in nitrous oxide and isoflurane %.K80 until delivery. (+s an alternative, 220 oxygen in nitrous oxide may be used in an attempt to ensure that there is no patient awareness. Beonatal outcome does not appear to be adversely affected by this reduction in inspired oxygen concentration (., 3) provided that maternal oxygenation is maintained). +tracurium (%.2 mg:&g) may be used to maintain relaxation.

# 4-5T#D6> !6)FE -nce the cord is clamped, .% units of synthetic oxytocin are given intravenously, and an infusion is commenced with $% units oxytocin in .%%%ml compound sodium lactate (lactated )inger*s) solution. + narcotic of choice (eg. pethidine ..8 mg:&g) is given, with or without an antiemetic (eg. droperidol %.%8 mg:&g), and the gas flow is ad?usted to produce an 7i-3 of %.22. # )6,-!6)FE 7ollowing adequate reversal with neostigmine:atropine, the patient should be extubated in the lateral position and transferred breathing oxygen to a recovery room. + similar induction technique should be used for all emergency general anaesthetics, both prior to delivery and in the first 3$ hours postpartum. )eferencesE .. >awes 6(, Bewman C, ,ampbell "@, et al. "aternal inspired oxygen concentration and neonatal status for caesarean section under general anaesthesia. ,omparison of effects of 220 or 8%0 oxygen in nitrous oxide. Critish @ +naesthesia ./11 =.E38%#38$. 3. 9odgson ,+, <auchob TD. + comparison of spinal and general anaesthesia for elective caesarean sectionE effect on neonatal condition at birth. nternational @ of -bstetric +nesthesia .//$ 2E38#2%. The safe provision of anaesthesia requires appropriate staff, facilities and equipment for proper patient safety. These are specified in this Document. 6) PR#'C#P3E! /& A'AE!T"ET#C CARE ... +naesthesia should be administered only by medical practitioners with appropriate training in anaesthesia or by trainees supervised according to ,ollege 4olicy Documents AThe 5upervision of Trainees in +naesthesiaA (62) and A4rivilees in +naesthesiaA (43). ..3 6very patient presenting for anaesthesia should have a pre#anaesthetic consultation by a medical practitioner who has appropriate training in anaesthesia. 5ee ,ollege 4olicy Document A4re#anaesthetic ,onsultationA (4K). ..2 +ppropriate monitoring of physiological variable must occur during anaesthesia. 5ee ,ollege 4olicy Document A"onitoring During +naesthesiaA (4.1).

7) !TA&&#'1 3.. n addition to the nursing staff required by those carrying out the obstetric or the operative procedure, there must beE 3.... +n assistant to the anaesthetist. 5ee ,ollege 4olicy Document A"inimum +ssistance for the 5afe ,onduct of +naesthesiaA (41). 7or the establishment and management of epidural bloc&ade for analgesia in labour, the presence of a midwife trained and competent in obstetric epidural management is required. 3...3 +dequate assistance in positioning the patient. 3...2 +dequate technical assistance to ensure proper servicing of all equipment used. 3...$ +t the time of delivery, there must be a medical practitioner with appropriate training in the resuscitation and care of the neonate with soleresponsibility for that tas&. 8) DE3#5ERY !0#TE! 2.. Anaesthetic Equipment 2.... <here general anaesthesia, sedation or ma?or regional bloc&ade are utilised, equipment must comply with the requirements set out below as well as with ,ollege 4olicy Document A5edation for Diagnostic and "inor 5urgical 4roceduresA (4/). <here a range of equipment is recommended, the hospital is expected to provide the type most suitableto its needs. <here patients are transferred to another facility for operative delivery, anaesthetic and resuscitative equipment is still essential for the management of complications of epidural and other ma?or regional bloc&ade. 2...3 6ach hospital must designateE 2...3.. -ne (or more) specialists to advise on the choice and maintenance of anaesthetic equipment.

2...3.3 -ne (or more) of its nursing or technical staff to be responsiblefor the organisation of clening, maintenance and servicing of anaesthetic equipment. 2...2 There must be an anaesthetic machine for each anaesthetising location which is capableof delivering air, oxygen, nitrous oxide as well as other anaesthetic agents which are in common use. 6ssential equipment includesE 2...2.. 5uitablecalibrated vaporisers for the delivery of inhalational anaesthetic agents. 2...2.3 + range of suitablebreathing systems. 2...2.2 "edical air where this is clinically necessary. 2...$ 5afety devices which must be present on every machine includeE 2...$.. +n indexed gas connection system. 2...$.3 + reserve supply of oxygen. 2...$.2 +n oxygen supply failure warning device (see ,ollege 4olicy Document A"onitoring During +naesthesiaA (4.1). 2...$.$ + breathing system high pressure relief valve. 2...$.8 +n oxygen concentration analyser with appropriate alarm limits (see ,ollege 4olicy Document A"onitoring During +naesthesiaA (4.1). 2...$.= 6very anaesthetic machine purchased after . @anuary .//= shall have a device to prevent the supply of a hypoxic gas mixture whenever nitrous oxide is administered. 2...$.K 6very anaesthetic machine purchased after . @anuary .//= shall have an approved non#slip connection for the common gas outle whenever a circlesystem is in use.

2...8 + separate means of inflating the lungs with oxygen must be provided in each anaesthetising location. This apparatus should comply with the current requirements of the releant national 5tandards. ts oxygen supply should be independent of the anaesthetic machine. 2...= 5uction apparatus must be available for the exclusive use of the anaesthetist at all times together with appropriate hand pieces and endotracheal suction catheters. This apparatus should comply with the current requirements of the releant national 5tandards. 4rovision must be made for an alternative suction system in the event of primary suction failure. 2...K n every anaesthetising location there should beE 2...K.. +ppropriate protection for the anaesthesia team against biological contaminants. This shall include disposable gloves and eye shields. 2...K.3 + stethoscope 2...K.2 + sphygmomanometer 2...K.$ "onitoring equipment complying with ,ollege 4olicy Document A"onitoring During +naesthesiaA (4.1). 2...K.8 +n appropriate range of face mas&s. 2...K.= +n appropriate range of oropharyngeal, nasopharyngeal and laryngeal mas& airways. 2...K.K Two laryngoscopes with a range of suitableblades. 2...K.1 +n appropriate range of endotracheal tubes and connectors. 2...K./ + range of endotracheal tube introducers.

2...K..% nflating syringe and clamps. 2...K... "agill*s forceps. 2...K..3 + suitablerange of adhesive and other tapes. 2...K..2 5cissors. 2...K..$ 5terileendotracheal lubricant. 2...K..8 !ascular tourniquets. 2...K..= ntravenous infusion equipment with an appropriate range of cannulae and solutions. 2...K..K "eans for the safe disposal of items contaminated with biological fluids as well as of AsharpsA and waste glass. 2...K..1 6quipment suitablefor the establishment of sub#arachnoid, epidural or regional nerve bloc&s. 2...K../ 4rovision for scavenging of anaesthetic gases and vapours with interface equipment which precludes over#pressurisation of the anaesthesia breathing circuit. 2...K.3% + cardiac defibrillator with capacity for synchronised cardioversion. 2...1 n every anaesthetising location there should be available 2...1.. 6quipment for managing difficult intubations . 2...1.3 6quipment for automatic ventilation of the lungs incorporating alarms as specified in ,ollege 4olicy Document A"onitoring During +naesthesiaA (4.1).

2...1.2 6quipment for the direct measurement of arterial and venous pressures. 2...1.$ 6quipment for the rapid infusion of fluids. 2...1.8 6quipment to minimise patient heat loss by warming of infused fluids and the body surface. 2...1.= 6quipment to warm and humidify gases administered during anaesthesia. 2...1.K nterpleral drainage sets. 2.../ -ther requirements for safe anaesthesia includeE 2.../.. +ppropriate lighting for the clinical observation of patients which complies with the current requirements of the releant national 5tandards. 2.../.3 6mergency lighting. 2.../.2 Telehone: ntercom to communicate with persons outside the anaesthetising location. 2.../.$ )efrigeration facilities for the storage of drugs and biological products. 2.../.8 The means to maintain room temperature in the anaesthetising location within the range of .1 # 31o,. 2.../.= 4atient transfer trolleys:beds as specified in ,ollege 4olicy Document A(uidelines for the ,are of 4atients )ecovering from +naesthesiaA (4$). 2....% n each delivery room there must beE 2....%.. +pparatus for the administration of inhalational analgesia with a minimum of 2%0 oxygen.

2....%.3 5uction apparatus for the exclusive use of the anaesthetist which is separate from that required for the resuscitation of the neonate. 2....%.2 5eparate oxygen outles and suitable attachments for administering oxygen to the mother and to the neonate. 2.3 Drugs 2.3.. n addition to the drugs and agents commonly used in anaesthesia, drugs necessary for management of conditions which may complicate or co#exist with anaesthesia must also be available +naphylaxis ,ardiac arrhythmias ,ardiac arrest 4ulmonary oedema 9ypotension 9ypertension Cronchospasm )espiratory depression 9ypoglycaemia 9yperglycaemia +drenal dysfunction )aised intracranial pressure Uterine atony Clood coagulopathy "alignant hyperpyrexia 2.3.3 n ma&ing an appropriate seletion of drugs for the management of these conditions, advice should be sought as in 2...3...

2.3.2 +ppropriate mechanisms must exist for the regular replacement of these drugs after use and:or their expiry date has been reached. 2.3.$ + basic supply of dantrolee should be rapidly availableto all anaesthetising locations with further doses being availableon request. 2.2 Routines for Checking, Clening and Servicing Equipment 2.2.. )egular sterilising, clening and house&eeping routines for the care of equipment should be established. 2.2.3 Documented servicing of the anaesthetic machine and medical gas equipment by an appropriate organisation must be carried out at lest twice a year. +fter any modification to the gas distribution system, gas analysis and flow measurement must be carried out and documented before use. 2.2.2 + copy of the ,ollege 4olicy Document A4rotocol for ,hec&ing an +naesthetic "achine Cefore UseA (T3) or a similar document should be availableon each anaesthetic machine. 2.$ Recovery Area 2.$.. )ecovery from anaesthesia should ta&e place under appropriate supervision in a designated area which conforms with ,ollege 4olicy Document A(uidelines for the ,are of 4atients )ecovering from +naesthesiaA (4$). 2.$.3 ,ontingency plans should exist which would allow rapid patient transfer in an emergency from the delivery suite or recovery areas to another appropriate area under adequate medical supervision. 2.8 Neonatal Resuscitation Equipment 2.8.. + suitablerange of equipment must be availableforE 2.8.... +dministration of oxygen to the neonate.

2.8...3 ntubation and ventilation of the neonate. 2.8...2 ,lering of the airway of the neonate. 2.8...$ +dministration of intravenous fluids and drugs. 2.8...8 "aintenance of the neonate*s temperature. 2.8.3 +n appropriate range of drugs must be available 2.8.2 t is recommended that each hospital designateE 2.8.2.. -ne (or more) medical practitioners with appropriate training and qualifications to advise on the choice and maintenance of equipment and drugs required for the resuscitation and care of the neonate. 2.8.2.3 -ne or more of its nursing or technical staff to be responsiblefor the organisation of clening, servicing and maintenance of this equipment.

4aracervical Cloc& >eonie <atterson 4aracervical bloc&ade may be used as a means of reducing pain during the first stage of labour. 4ain associated with uterine contraction and cervical stretching and dilatation is transmitted from these structures on visceral afferents which accompany sympathetic fibres. These pass sequentially through the uterine, cervical, inferior hypogastric and superior hypogastric plexuses to the lumbar and lower thoracic sympathetic chains. During early labour, the bul& of these enter the spinal cord at the T.. # T.3 segments. +s pain becomes more severe, the two ad?acent segments, T.% and >. become involved (.) (7igure $=..). The bloc& is performed bilaterally with the patient in the lithotomy position. The proximity of the broad ligaments ?ust deep to the lateral fornices of the vagina is exploited with the aim of interrupting pain transmission at the level of the uterine and pelvic plexuses (3) (7igure $=.3). +n .1.8 cm needle with a security tip ( owa trumpet, Goba&) is used to limit the in?ection to within ..8 # 3 cm of the

epithelium. The needle is connected to a 3% ml >uer#>o& syringe. "easures to avoid intravascular in?ection are vital. +fter careful aspiration non#adrenaline containing local anaesthetic solution is infiltrated. The specific in?ection sites have been variously describedE 2 and / ocloc&D $ and 1 ocloc&D or alternatively all sites (3, 2). The distribution of radio#opaque dyes observed in H#ray studies is similar ($). +n interval of .8 minutes should be observed between in?ections during which time signs of maternal (Table 2=.$) and fetal toxicity should be excluded. 4aracervical bloc&ade can be used to provide analgesia during the first stage of labour when contraindications of epidural analgesia are present (,hapter 3). The optimal time for institution of this bloc& is the accelerated phase of the first stage when the severity of pain increases. The presenting part is typically engaged. The cervix is thin and effaced and has a tendency to be drawn up during uterine contractions (3). 4aracervical bloc&ade does not provide analgesia of the perineum during the second stage during which pain is transmitted primarily via the pudendal nerves to the 53 # $ spinal cord segments (7igure 3...). The technique has several limitations. The failure rate is reported to be as high as .10 (8). The proximity of uterine blood vessels in the vaginal fornices creates maternal and fetal ris&s. 7etal bradycardia occurs in .%#8%0 of cases (=). This is attributed to asphyxia which is believed to result from transient uterine artery vasospasm due to high concentrations of local anaesthetic in the paracervical region. The technique has a duration of action limited to /% minutes with plain lignocaine. The use of adrenaline or bupivacaine in an attempt to increase the duration of the bloc& should be avoided as both increase the incidence of fetal bradycardia (3, 2). )eferencesE .. Conica @@E -bstetric +nalgesia and +nesthesia <orld 7ederation of 5ocieties of +naesthesiologists +msterdam 3nd ed. ./1%. 3. Goba& +@, 5adove "5E ,ombined paracervical and pudendal nerve bloc&s# a simple form of transvaginal regional anesthesia +m. @. -bst. (yn. ./=.D 1.EK3 2. "arx (, Cassell ( ed D -bstetric +nalgesia and +nesthesia "onographs in +naesthesiology , vol K 6xcerpta "edica Bew For&, ./1% p322#328. $. 5panos <@, 5teele @,E -bstet (ynecol ./8/D .2E .3/.

4ost#partum +lternatives to a 5pinal 6;;at +bouleish . 6pidural +nesthesia (6.+)E 6pidural anesthesia offers no advantages over spinal anesthesia (,hapter =K) and should not be considered for a short procedure li&e post#partum tubal ligation unless an epidural catheter is already in place after its use for delivery. <hen 6.+. is reinstated many hours after the delivery, certain precautions should be ta&enE .) + history of the reliability of 6.+. for labor should be confirmed. 3) The patient*s bac& should be examined to ensure that an appropriate length of the catheter is still present. The catheter may be displaced by too much movement of the patient, inadequate taping or perspiration.

2) The first .% ml of the local anesthetic should be in?ected with the patient on her side to exclude lea&age of the catheter or superficial position of its tip, which can lead to subcutaneous crepitus or swelling. $) f epidural in?ection of an adequate dose of a local anesthetic (e.g. 3% to 2% ml of 20 chloroprocaine) cannot achieve an adequate bilateral level of bloc& (i.e. at least T= dermatomal level), spinal anesthesia should be considered rather than struggling with an inadequate bloc& and exposing the patient to its dangers. The use of spinal anesthesia immediately after verification of inadequate 6.+. and after administration of a large dose of a local anesthetic sometimes leads to an excessively high bloc&. The mechanism of this occurrence is multifactorial. ,.5.7. volume may have decreased owing to its compression by the epidurally in?ected large volume of local anestheticD both techniques may have had an additive effectD or lea&age of the epidurally in?ected local anesthetic into the subarachnoid space through the hole created in the dura. The dose of spinal should be reduced by one third, or the epidural bloc& should be allowed to wear off before administering a spinal anesthetic. . ,ombined 5pinal and 6pidural Technique (,56) (,hapter =3)E This technique for both delivery and tubal ligation is an excellent alternative. The analgesia for early labor can be conducted using intrathecal .% mcg sufentanil with or without 3.8 mg bupivacaine (.ml %.380). (., 3) The analgesia begins almost instantaneously. +lthough the addition of a small dose of bupivacaine (3.8 mg) does not have any significant effect on motor power, it does prolong the duration and improve the quality of analgesia . +fter the spinal component of the bloc& wears off, the epidural part can be initiated in the regular manner. To avoid a period of pain between the two parts of the technique, the epidurally in?ected local anesthetic should be started as soon as the patient feels discomfort. +fter delivery, 6.+. can also be used for tubal ligation as described earlier. . ,ontinuous 5pinal +nesthesia (,.5.+)E <ith ,.5.+, analgesia for labor can be obtained by the use of an intrathecal narcotic with or without a local anesthetic as described above for ,.5.6. +fter delivery, the level and intensity of the bloc& can be achieved by titrating hyperbaric bupivacaine dosage (%.K80 in 1.380 dextrose) to achieve a T$ dermatomal level. ,.5.+. can be initiated from the start or an attempted 6.+. can be converted to ,.5.+. after inadvertent dural puncture. This alternative is simpler and safer than a repeated attempt to perform 6.+. )eferencesE .. +bouleish +., +bouleish 6, ,amann <E ,ombined spinal#epidural analgesia in advanced labour. ,an @ +naesth .//$D $.E 8K8#8K1.

3. ,ampbell D,, ,amann <), Datta 5E The addition of bupivacaine to intrathecal sufentanil for labor analgesia. +nesth +nalgD 1.E 2%8#2%/.