ANESTHESIA AND ANALGESIA

IN OBSTETRICS

SUBMITTED TO:- SUBMITTED BY:-

Mrs. Kamlesh Rani Rakhi Sharma

Associate professor Msc 1st yr
 Labor Analgesia:-
It refers to relief of pain in labor with
pharmacological and non-pharmacological
methods.

 Anesthesia:-
It refers to complete block of pain sensation
with or without loss of consciousness. This is
used during cesarean delivery and for some
obstetric procedures.
 LABOR ANALGESIA
Non Pharmacological
•Prenatal/ Antenatal education
•Rhythmic breathing technique
•Continuous labor support
•Touch and massage
•Warm water births
•Music
•Acupuncture & Acupressure
•Transcutaneous electrical nerve
stimulation
Pharmacological
•Sedatives and analgesics
•Inhalational analgesia
•Neuraxial analgesia
•Infiltration analgesia
-Epidural analgesia
-spinl analgesia
-combined epidural and
spinal analgesia
•General anesthesia
 NON PHARMACOLOGICAL METHOD
 Prenatal/antenatal education:-
- When women is well informed about labor
process and what to expect during labor, she
will be able to cope better with labor pain.
 Continuous labor support:-
• Husband in labor room, can provide
emotional support during labor and help the
woman cope.
NON PHARMACOLOGICAL METHOD cnt…

Rhythmic breathing techniques:-

 Rhythmic controlled breathing allows the
woman to divert her mind from pain.
 It contributes to her ability to cope with
labor pain.
 Women express high satisfaction with
breathing techniques.
NON PHARMACOLOGICAL METHOD cnt…

 Touch and massage:-

• When a woman is feeling helpless in labor, a
caring and reassuring touch by another
person can be very comforting.
• Massage of low back and thigh also helps to
relieve some of pain.
NON PHARMACOLOGICAL METHOD cnt…

 Warm water bath:-

• Immersion in warm water bath has been
shown to be soothing.
 Music:-
• Playing music in labor room helps to divert
the woman’s mind from pain and helps her to
cope better
NON PHARMACOLOGICAL METHOD cnt…

 Acupuncture and acupressure:-

• In acupuncture needles are placed at specific
points on body and in acupressure ,pressure
is applied at specific point.
• It leads to high satisfaction and reduction in
dosage of analgesics.
NON PHARMACOLOGICAL METHOD cnt…

 Transcutaneous electrical nerve stimulation:-

• In this electrical impulses are transmitted to skin
via electrodes.
• It helps to relieve pain in labor.
 Application of heat and cold, hypnosis, and
aromatherapy are other nonpharmacological
methods.
 PHARMACOLOGICAL METHODS
SEDATIVE AND ANALGESIC

i. Pethidine (Mepridine) :-
• Most commonly used, has strong sedative but
less analgesic efficacy.
• Generally used in first phase of labor.
 PHARMACOLOGICAL METHODS cnt…

• Dose:- - IM (commonly used) :-50-100mg ( 1-2

mg/kg body wt) , can be repeated after 4-6 hrs if
woman has not delivered yet.
- IV :- 25 mg every 2 hrs.
• Onset of action:- - within 45 min after IM
administration.
- Almost immediate after IV administration.
 PHARMACOLOGICAL METHODS cnt…

• Side effects:- - Nausea, vomiting, delayed

gastric emptying.
- Cross the placenta and accumulates in fetal
tissues .
- Depress the respiration and suckling of
newborn when administered before delivery.
• Rantidine should be given to inibit gastric acid
production and metoclopramide for vomiting.
 PHARMACOLOGICAL METHODS cnt…
ii. Fentanyl:-
• Lipid soluble synthetic opioid, with analgesic
potency 100 times that of morphine and 800
times that of pethidine.
• Remifenatnil is also gaining popularity.
• Dose :- IV bolus of 25-50 ug (given slowly over 1-2
minutes) every hour.
 PHARMACOLOGICAL METHODS cnt…

 Onset of action :- Rapid within 2-3 minutes with

short duration of action, making it useful for
labor analgesia
 Side effects:- - less neonatal effects and less
maternal nausea and vomiting than others.
 Performs better in terms of pain scores in
women in labour.
 PHARMACOLOGICAL METHODS cnt…
iii. Tramadol:-
 Synthetic opioid analgesic.
 Potency is 10% of pethidine.
 Dose :- 100 mg IM (1-2mg/kg body wt )
 Onset of action:- within 10 minutes after
administration and effect lasts for 2-3 hrs.
 Not as effective as pethidine.
 Causes no clinically significant respiratory
depression.
 PHARMACOLOGICAL METHODS cnt…

iv. Phenothiazines:-
 Promethazine (phenergen) is commonly used in
labour in combination with an opioid.
 Weak antiemetic drug.
 Side effects:- - cause sedation in mother.
- Does not cause major neonatal depression.
 PHARMACOLOGICAL METHODS cnt…

v. Butorphanol:-
 It is an opioid, 5 times as potent as morphine and
40 times as potent as pethidine.
 Offers analgesia with sedation.
 Dose:- 1-2 mg IM.
 Side effects:- produce excessive sedation, so not
used frequently for labor analgesia.
 PHARMACOLOGICAL METHODS cnt…
 Narcotic antagonists:- It is used to reverse the
respiratory depression induced by opioid
narcotics.
 Nalaxone is given to mother 0.4mg IV in labour.
 It is given to newborn 10 ug/kg IM or IV and is
repeated as necessary.
 It is given to a newborn of a narcotic addicted
mother with proper ventilation arrangement
otherwise withdrawal symptoms are
precipitated.
 PHARMACOLOGICAL METHODS cnt…
Patient control analgesia:-
 Intravenous analgesia, where the woman herself
controls the frequency of administration.
 Provides good pain relief in labor.
 Used in women who desire continuous analgesia
but where epidural analgesia is contraindicated.
 Maternal respiration should be closely
monitored.
 PHARMACOLOGICAL METHODS cnt…

 Fentanyl and remifentanilare drugs used in it.

 Doses:-
• Fentanyl – 20-60 ug every 5-10 minutes
• Remifentanil – 25-50 ug every 5-10 minutes
 PHARMACOLOGICAL METHODS cnt…

 Benzodiazepines ( Diazepam) :-
 It is sedative and well tolerated by the patient,
however diazepam is avoided in labour.
 May be used in larger doses in the management
of pre-eclampsia.
 Dose:- 5-10 mg.
 Metabolised in liver.
 PHARMACOLOGICAL METHODS cnt…
 Disadvantages :- - Loss of beat to beat variability
in labour.
- Neonatal hypotonia
- Hypothermia
 Flumazenil:- - specific benzodiazepine
antagonist.
- It can reverse the respiratory depression effect of
benzodiazepines.
 PHARMACOLOGICAL METHODS cnt…
INHALATIONAL ANALGESIA
 Nitrous oxide inhalational analgesia is
administered as a blend of 50% nitrous oxide
and 50% oxygen.
 Used in:- Second phase (from 8 cm dilation of
cervix to delivery) .
 Etonox apparatus has been approved for use by
midwives.
INHALATIONAL ANALGESIA
 INHALATIONAL ANALGESIA
 Laboring woman uses a handheld face mask
to self administer the anesthetic gas.
 Takes 50 seconds to take effect.
 Woman is instructed on correctly timing for
each inhalation.
 Woman is to take slow and deep breaths before
the contractions and to stop when the
contractions over.
 INHALATIONAL ANALGESIA
 Side effects:- Hyperventillation, dizziness,
hypocapnia .
 The woman should be monitored with pulse oximetry
 It is safe because when the woman becomes drowsy,
she will automatically drops the mask.
 Provides significant degree of pain relief and may be
useful in situation where epidural analgesia is not
available.
 Does not cause neonatal respiratory depression or
affect contractility.
 INFILTRATION ANALGESIA
 Perineal infiltration :- 1.) For episiotomy-
• Extensively used prior to episiotomy
• 10 ml syringe , with a fine needle and about 8-10 ml
1% lignocaine hydrochloride required.
• The perineum on the proposed episiotomy site is
infiltrated in a fan-wise manner starting from the
middle of the fourchette.
• Each time prior to infiltration, aspiration to exclude
blood is mandatory.
• Episiotomy is to be done about 2-5 minutes following
infiltration.
 INFILTRATION ANALGESIA
2.) For outlet forceps or ventouse –
• Combined perineal and labial infiltration is effective
in outlet forceps operation or ventouse traction.
• 20 ml syringe, a long fine needle and about 20 ml of
1% lignocaine hydrochloride are required.
• Needle is inserted just posterior to the introitus.
• The needle is then directed anteriorly along each side
of vulva as far as anterior-third to block genital
branch of genitofemoral & ilio-inguinal nerve.
• 5 ml is required to block each side .
 INFILTRATION ANALGESIA
3.) Local abdominal for caesarean delivery-
• Rarely used where regional block is patchy or
inadequate.
• Skin is infiltrated along the line of incision with
diluted solution of lignocaine (2%) with normal saline.
• Subcutaneous fatty layer, muscle, rectus sheath
layers are infiltrated as layers re seen during
operation.
• Operation should be done slowly foor the drug to
become effective
 NEURAXIAL ANALGESIA
 Provide best pain relief in labor and widely used.
 A local anesthetic with or without an opioid is
injected into the epidural or interathecal space close
to spinal nerves that tansmit pain from uterus to the
spinal column (T10-L1).
 The dose is adjusted to provide analgesia without
affecting motor function and appreciation of pressure
during uterine contraction.
 May be epidural, spinal, or combined epidural &
spinal analgesia
 NEURAXIAL ANALGESIA
Epidural Analgesia
 It is a central nerve block technique accomplished
by injecting a local anesthetic.
 Primary goal of neuraxial analgesia during labor
or vaginal delivery is to provide adequate
maternal analgesia with minimal motor block.
 It achieves this when a local anesthetic(eg.
Bupivacaine) is used at low conc. With or without
opioids(eg. Fentanyl).
 Epidural Analgesia
 Contraindications:- Maternal coagulopathy
• supine hypotension
• thrombocytopenia
• raised intracranial pressure
• anticoagulant therapy
• hypovolaemia
• neurological diseases
• spinal deformity
• skin infection at injection site
 Epidural Analgesia
 Procedure:-
• A preload 500 ml of iv fluids should be given prior to
administering epidural analgesia.
• Aseptic precautions must be used (gown, gloves,
masks, and providine-iodine skin prep).
• Epidural block can be performed in the lateral or
sitting position.
• Lumbar supine is palpated and the widest
interspace below L3 is chosen.
• A local anesthetic is used to numb the skin.
 Epidural Analgesia
 A spinal needle is slowly advanced while feeling
for resistance. A sudden loss of resistance is felt as
the epidural needle enters the epidural space.
Care is taken not to puncture the dura. An epidural
catheter is threaded through the needle and the
needle is removed.
 The catheter is fixed in place.
 A combination of low conc. Bupivacaine and
fentanyl is given as bolus every 2 hours or as needed
to maintain maternal comfort.
 Epidural Analgesia
 Drugs used:- - Local anesthetic- Bupivacaine
- opioid- Fentanyl
 Precaution :- - Blood pressure should be recorded
prior to administration of an epidural . Thereafter it
should be checked at 5-15 minutes intervals.
- Continous fetal heart rate monitoring should be
done since the epidural may cause maternal
hypotension, leading to fetal heart rate
abnormality.
 Epidural Analgesia

 Complications:- - Hypotension
- Nausea and vomiting
- Pain at insertion site , back pain
- Post spinal headache due to leakage of CSF
through needle hole in dura
- Ineffective analgesia
- Injury to nerve, convulsions, pyrexia
- Fetal heart rate abnormality
 Effect of epidural analgesia on
labor
 Timing of epidural analgesia has no effect on labor
progression, therefore it is not necessary to wait until the
active phase of labor for administration of epidural
analgesia.
 It prolongs active phase of labor by 1 hour.
 Due to motor blockade induced by analgesic, the
duration of second stage is prolonged.
 Is not associated with any increase in adverse neonatal
outcome.
 Need for operative vaginal delivery for prolonged stage is
higher
 Pudendal Block
 Safe and simple method of analgesia during
delivery.
 It does not relieve the pain of labour but affordds
perineal analgesia and relaxation.
 Indication:- - outlet forcep delivery
- Assisted breech delivery
- Repair of episiotomy and perineal lacerations.
 Pudendal Block
 Procedure:- - it should be performed with all aseptic
precautions.
- Woman is placed in dorsolithotomy position.
- Perineum should be prepared with providine iodine
solution
- Sterile gloves must be used.
- 1% solution of lidocaine is used.
- 20 gauge , 15 cm spinal needle is used.
- Usually a transvaginal approach is used , although a
transperineal approach has been described.
- Pudendal nerve lies behind sacrospinous ligament
that stretches between ischeal spine and sacrum.
 Pudendal Block
- Ischeal spine is palpated with the index and middle
fingers and the needle advanced for a distance of
1 cm through the vaginal mucosa into the sacrospinous
ligament. A needle guide may be used, if available.
- Syringe is aspirated to ensure that needle has not
entered a blood vessel.
- If no backflow of blood, 3 ml of the anesthetic solution is
injected into sacrospinus ligament.
- Needle is then advanced through the sacrospinous
ligament into loose areolar tissue around pudendal
nerve.
 Pudendal Block
- After aspirating to ensure no vascular puncture,
another 7 ml of anesthetic solution is injected into
this area.
- Procedure is repeated on other side.
 Complications:- - hematoma formation from
perforation of blood vessel during needle insertion
- Infection at injection site.
- Ischial region paresthesias and sacral neuropathy.
- Seizures, hypotension, cardiac arrhythmias after
IV administration.
 Paracervical Block
 Relief pain during first stage of labour.
 Block visceral sensory fibers of lower uterus , cervix
& upper vagina.
 Not affect progression of labor.
 Does not block sensory nerves from perineum, so
not effective in 2nd stage of labor.
 Can be given only after a cervical dilatation of 4 cm
& may need to be repeated every 1-2 hrs .
 Not used commonly for pain relief during labor.
 Paracervical Block
 Procedure:- - Maintain asepsis, place woman in
dorsolithotomy position and Prepare vagina and
perineum with providine-iodine solution.
- Two fingers are used to direct the tip of guide into the
lateral vaginal fornix. Care must be taken to interpose
the fingers between the cervix or fetal head and
needle. Needle guide may be used.
- The needle is usually inserted close to cervix at 3 and 9
o’ clock positions in lateral fornix (imagining the cervix
as a clock face), some authors suggest 4 and 8 o’ clock
positions to avoid blood vessels.
 Paracervical Block

- Needle is inserted into vaginal mucosa for a depth

of 3-5 mm.
- Syringe is aspirated to rule out needle position in
blood vessel.
- If there is no backflow of blood, 5ml of anesthetic
solution(1% lignocaine with adrenaline) is injected
into vaginal submucosa. Injecction is avoided
during contractions.
- Repeat process on other side.
 Paracervical Block
 Contraindicate if placental insufficiency is present.
 Bupivacaine is avoided due to its cardiotoxicity.
 Complications:- - Postblock fetal bradycardia:- occur
within 10 minutes of injection and usually transient
but last as long as 40 minutes.
- Systematic toxicity:- occur after admministration &
may result in excessive sedation, generalized
convulsions, and cardiovascular collapse.
- Lower extremity paresthesias
- Vaginal/ broad ligament hematoma or infection is rare
 Transvaginal route

 Commonly preffered .
 Procedure:- - 20 ml syringe , one 15 cm 22 gauge
spinal needle and 20 ml of 1% lignocaine
hydrochloride required.
 Index and middle fingers of one hand are
introduced into vagina, finger tips are placed on tip
of ischial spine of one side.
 Transvaginal route
- Needle is placed along groove of spinous ligament
just above ischial spine tip.
- After aspirating to exclude blood, about 10 ml of
solution is injected.
- Repeat prrocedure on other side.
 Complication:-
- Hematoma formation
- infection
 SPINAL ANAESTHESIA
 Spinal anesthesia is achieved by a subarachnoid
injection of a local anesthetic ( bupivacaine) and an
opioid ( fentanyl).
 In a woman undergoing a vaginal delivery, spinal
anesthesia is not used for labor analgesia because
the effect lasts only for a short time (90-120 min).
 It may be used for short obstetric procedures such
as forceps, vacuum delivery, or manual removal of
placenta.
 It is choice for a cesarean section.
 SPINAL ANAESTHESIA
 Advantages over epidural analgesia:-
- Short procedure time
- Rapid onset of the block (within 5 minutes)
- High success rate
 Procedure:- - A preload of 500-1000 ml of IV fluids is
given to prevent hypotension resulting from sympathetic
block from spinal anesthesia.
- Procedure is done under aseptic precautions.
- Woman can be sitting or lying on her side.
- Woman is instructed to arch her back since flexion of
spines opens the intervertebral spaces
 SPINAL ANAESTHESIA
- The L3/4, L4/5, or L5/S1 interspace is identified.
- The chosen interspace is infiltrated with a local
anesthetic.
- Spinal needle is inserted in midline.
- Resistance increases as the ligamentum flavum is
entered and when the dura is encountered, with a
sudden ‘give’ as dura is pierced.
- Correct placement of needle is confirmed by a drop
of clear CSF appearing at the hub of the needle
when the stilette is removed.
 SPINAL ANAESTHESIA

 Complications:- - Hypotension
- Nausea and vomiting
- Pruritis
- Postdural puncture headache
- High spinal ( cephalad progression of the level of
anesthesia.
 COMBINED SPINAL-EPIDURAL
ANESTHESIA
 Provides rapid onset of action of spinal and longer
duration of action of an epidural.
 It is not a routinely practical technique.
 Procedure:- - Placing a needle into the epidural space.
- Another smaller- gauge needle is then threaded through
this into the subarachnoid space.
- After injecting drugs into spinal space, a catheter is
inserted into the epidural space for additional drug
injection.
 GENERAL ANESTHESIA
 Indications:- - Cesarean section
- Removal of retained placenta
- Suturing of extensive vaginal or perineal tears after
vaginal delivery.
- Management of acute uterine inversion
 General anesthesia is indicated for cesarean section
in following situations:-
 - Emergency cesarean section where anesthesia has
to be induced without delay due to fetal condition.
 Failed/ inadequate spinal or epidural anesthesia.
 GENERAL ANESTHESIA
 Important consideration for caesarean section:-
• Caesarean section may have to be done either as an
elective or emergency procedure.
• Fasting of 6-8 hrs is preferable for elective surgery.
• Large no. of drugs pass through placental barrier and
may depress the baby.
• Uterine contractility may be diminished by volatile
anesthetic agent like ether, halothane.
• Hypoxia and hypercapnia may occur.
• Time interval from uterine incision to delivery is related
directly to fetal acidosis and hypoxia.
 GENERAL ANESTHESIA
 Preoperative medication with sedatives or narcotic
is not required , as they may cause respiratory
depression of fetus.
 Procedure:- - 100% oxygen is administered by tight
mask fit for more than 3 minutes.
- Induction of anaesthesia is done with the injection
of thiopentone sodium 200-250 mg (4 mg/kg) as 2.5
percent solution intravenously, followed by
refrigerated suxamethonium 100mg.
- Patient is intubated with a cuffed endotracheal tube
and cuff is inflated.
 GENERAL ANESTHESIA
- Anesthesia is maintained with 50% Nitrous oxide,
50% oxygen and a trace (0.5%) of halothane.
- Relaxation is maintained with nondepolarising
muscle relaxant ( Vencuronium bromide 4 mg or
Atracurium 25 mg ).
- After delivery of the baby, the nitrous oxide
concentration should be increased to 70% and
narcotics are injected intravenously to supplement
anaesthesia.
 GENERAL ANESTHESIA
 Complication:- - Aspiration of gastric contents (
Mendelson’s syndrome):- it leads to chemical
pneumonitis, atelectasis and bronchopneumonia.
- Neonatal effect:- respiratory depression.
 Safety measures to prevent complication:-
• H2 blocker ( rantidine 150 mg orally) should be given
night before & to repeated one hour before
administration of general anesthesia.
• Metoclopromide is given after minimum 3 minutes of
preoxygenation.
• Awake extubation should be routine.