CMED 321 LABOR ANALGESIA AND ANESTHESIA
Lecturer Dr. Morin Trans scriber/s JP Barraquia
Definition of Terms
A. Labor Analgesia and Anesthesia
 Method of relieving a patient in labor from pain during uterine
contractions and safely anesthetizing patient during delivery
B. Parturient
 patient in labor
C. True Labor
 Contractions occur at regular interval
 Intervals gradually shorten(at the start of labor, contractions
may be within 10-20 minutes, and as the labor progresses
contractions become shorter, so contractions may occur
between 5-10 minutes until it becomes 2-3 minutes)
 Intensity gradually increases( Initially, pain is tolerable, of
course when contractions become stronger, intensity of pain
will become higher)
 Discomfort is in the back and abdomen
 Cervix dilates
 Discomfort is not alleviated by sedation
D. False Labor
 Contractions occur at irregular interval
 Intervals remain long(sometimes contraction may occur once
or twice in a day)
 Intensity remains unchanged
 Discomfort is chiefly in the chiefly in the lower abdomen
 Discomfort is usually alleviated by sedation
PREOPERATIVE EVALUATION AND INFORMATION
1. NAME
2. AGE
3. LAST MEAL(important because risk of aspiration and best to put
patient in NPO between 6-8 hours prior to OR)
4. OCCUPATION
5. RELIGION
6. ALLERGIES
7. COEXISTING DISEASES(COMORBIDITIES)
8. LABORATORY RESULTS
9. PHYSICAL EXAM
10. PROCEDURE AND INFORMED/SIGNED CONSENT
PULMONARY SYSTEM CHANGES IN PREGNANCY
A. Most significant changes in the pulmonary system during pregnancy
include alterations in:
 The Upper Airway
 Minute Ventilation
 Arterial Oxygenation
 Lung Volumes and Capacities
B. Upper Airway
 significant capillary engorgement of the mucosal lining of the
upper respiratory tract and increased tissue fragility
 these changes result to tissue edema of the vocal cords and
the arytenoids and prone to bleeding
 direct laryngoscopy and endotracheal intubation becomes
more difficult
 use of smaller sized endotracheal tubes (usually if we
intubate females, we use 7 to 7.5 endotracheal tube; for
pregnant, you can ask between 6.5 to 7)
*Legend: Additional notes – color RED
Date Jan. 8 2019
Fig 1.Tracheal Opening (Among pregnant patients, it is edematous. So
when you do laryngoscopy, you might not see its opening.)
C. Minute Ventilation (minute respiratory volume) and Oxygenation
 total amount of new air moved into the respiratory passages
each minute
 TV (volume of air inspired or expired with each normal
-12/min)
 approximately 6L/min
 Increased by about 50% above the pre-pregnant state during
the first trimester and maintained throughout pregnancy
 achieved primarily because of the increase in tidal volume (by
40-45%) and slight increase in RR (15%)
 increased circulating levels of progesterone and increased
CO2 production are the likely stimuli for the increased minute
ventilation
 resting maternal PaCO2 decreases from 40 mmHg to 30
mmHg as a reflection of the increased minute ventilation
 maternal ABG remains only mildly alkalotic because of the
increased renal excretion of bicarbonate ions of
approximately 20-21 mEq/L at term
 at term, oxygen consumption is increased by 20%
 the maternal oxyhemoglobin curve is shifted to the right
(oxygen is easily removed from hemoglobin because of need
of oxygen)
 the added work of labor further increases both in minute
ventilation and oxygen consumption
 oxygen consumption increases by 40% above prelabor state
during the first stage of labor and by 75% during the second
stage of labor
 pain of labor can cause severe hyperventilation and alkalosis
 attenuated by neuraxial analgesic techniques
D. Lung Volumes and Capacities
 the expiratory reserve volume (maximum extra volume of air
that can be expired by forceful expiration after the end of a
normal tidal expiration 1100mL) and the residual volume (the
volume of air remaining in the lungs after the most forceful
expiration 1200mL) do not begin to change (decreased) until
about the third month of pregnancy
 the functional residual capacity (the amount of air that
remains in the lungs at the end of normal expiration 2300
mL) decreases by 20% at term because of the cephalad
displacement of the diaphragm by the gravid uterus
 FRC is smaller than the closing capacity of many small airways
atelectasis during supine position
 the vital capacity (maximum amount of air a person can expel
from the lungs after first filling the lungs to their maximum
extent and then expiring to the maximum extent 4600 mL) is
not significantly changed with pregnancy
E. Anesthetic Implications
 during induction of general anesthesia in a pregnant patient,
PaO2 decreases much more rapidly than a non-pregnant
patient because of decreased oxygen reserve(decrease FRC)
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 CMED 321 LABOR ANALGESIA AND ANESTHESIA
and increased oxygen demand will increased risk of
hypoxia/hypoxemia, thus the need for adequate pre-
oxygenation
 during regional anesthesia in an awake pregnant patient,
since FRC is less than the closing capacity, patients in supine
position are at risk for atelectasis so you will oxygenate
patient throughout the procedure and encourage deep
breathing but avoiding hyperventilation
Fig 2. Pulmonary Changes in Pregnancy (take note of Vital Capacity is
the only that does not have any change)
CARDIOVASCULAR SYSTEM CHANGES IN PREGNANCY
A. Changes in the cardiovascular system during pregnancy can be
summarized as :
 An increase in the intravascular „fluid volume
 An increase in cardiac output
 A decrease in systemic vascular resistance
 Presence of aortocaval compression
B. Intravascular Fluid and Hematology
 maternal intravascular fluid volume begins to increase in the
first trimester
 progesterone stimulates aldosterone production (increasing
Na and water reabsorption from the renal tubules), whereas
estrogen enhances renin activity which modulates water
absorption
 at term, plasma volume increases about 50% above the non-
pregnant state, whereas the erythrocyte volume increases
only about 25%
 this disproportionate increase in plasma volume accounts for
the relative anemia of pregnancy (dilutional anemia),
although anemia in pregnancy is usually secondary to iron-
deficiency
 Hemoglobin normally remains at 11 g/dL or higher and
hematocrit > 33%
 the expanded intravascular fluid volume of 1-1.5L at term
offsets the 300-500mL blood loss that accompanies normal
delivery and the average 800mL to 1L blood loss during
cesarean section
 the total plasma protein concentration is decreased as a
result of the dilutional effect of the increased intravascular
volume
 pregnancy is a hypercoagulable state with concentration
increases in factors I, VII, VIII, IX, X, and XII; and a decrease in
factors XI, XIII and antithrombin III
 this results in an approximate 20% decrease in prothrombin
and partial thromboplastin time
 platelet count may be normal or decreased by 10% by term
 leukocytosis is common with neutrophil as the dominant
WBC; due to the stress caused by pregnancy itself on the
body
*Legend: Additional notes – color RED
C. Cardiac Output
 it increases by about 35% by the end of the first trimester and
increases to 50% above baseline by the third trimester
because of increases in both stroke volume (25-30%) and
heart rate (15-25%)
 additional increases of 10-25% in cardiac output occur with
the onset of the first stage of labor and 40% in the second
stage
 the largest increase occurs immediately after delivery when
cardiac output is increased by 80% above prelabor values
because of autotransfusion from the contracted uterus
 this presents a unique postpartum risk for patients with
cardiac disease (e.g. Mitral stenosis)
 cardiac output decreases within the first hours after delivery
and reaches prelabor values 48 hours postpartum
 it decreases substantially to its prepregnant state by 2 weeks
postpartum
D. Systemic Vascular Resistance
 arterial blood pressure decreases in an uncomplicated
pregnancy due to a 20% reduction in systemic vascular
resistance at term
 systolic, mean, and diastolic blood pressure all decrease by 5-
20% by 20 weeks of gestational age and gradually increase
toward pre-pregnant values as the pregnancy progresses
further
 the decreased SVR results in part from the blood flow
through the developing low resistance vascular bed of the
intervillous space(placenta), where blood vessels are
constantly dilated

blood vessels that results in increased renal, uterine ad
extremity blood flow
 there is no change in the central venous pressure despite the
increased plasma volume because of the increased venous
capacitance
E. Aortocaval Compression
 vena cava compression by the gravid uterus can also produce
pooling of venous blood and increased venous pressure in
the lower torso and extremities, causing phlebitis and venous
varicosities in pregnancy; also decreases cardiac output by
10-20%
 when there is complete vena cava occlusion, venous return of
blood from the lower extremities to the heart is through the
epidural, azygos and vertebral veins draining to the SVC to
the heart
Fig. 3: Aortocaval Compression (the patient was tilted to the left so that
the compression on vena cava is released, why to the left? Because aorta
is has higher pressure,so less likely to be compressed compared to the
vein)
F. Echocardiography/Electrocardiography Changes
 heart is displaced anteriorly and leftward (LAD)
 Right-sided chambers increase in size by 20% and left-sided
chambers increase in size by 10-20% with an associated left
ventricular eccentric hypertrophy and increase in ejection
fraction
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 CMED 321 LABOR ANALGESIA AND ANESTHESIA

 Mitral, tricuspid, and pulmonary valve annuli diameters

increase, but the aortic annulus remains unchanged resulting
to grade I-II systolic heart murmur caused by the increased
blood flow and valvular dilatation
 a third or fourth heart sound may occasionally be heard in
late pregnancy (Not all murmurs especially systolic is
pathologic among pregnant women)
 tricuspid and pulmonary valve regurgitation is common, and
25% of pregnant women have mitral regurgitation
 may have small insignificant pericardial effusions
 may have benign dysrrhythmia: reversible ST, T and Q wave Fig. 4: Cardiovascular Changes in Pregnancy
changes
 Cardiac Findings Indicating Heart Disease in Pregnancy:
- Systolic murmur greater than grade III (severe MS) GASTROINTESTINAL CHANGES IN PREGNANCY
- ANY diastolic murmur (severe MR or MVP)  cephalad displacement of the of the stomach by the gravid
-Severe arrhythmia (PVCs, PACs, AF, SVT) uterus changes the angle of the gastroesophageal junction,
-Unequivocal cardiac enlargement (dilated cardiac making the esophageal sphincter incompetent, causing
myopathies) gastric reflux and production of esophagitis and heartburn in
 always correlate with history, lab results and PE 45-70% of pregnant women
G. Compensatory Responses and Risks  Gastrin produced by the placenta raises the acid, chloride
 in supine position, significant arterial hypotension is volume and enzyme content of the stomach to level above
uncommon because the patient compensates for a decrease prepregnant state
in preload by reflex increases in systemic vascular resistance  increased levels of progestrone and the upward and
 the compensatory increase in vascular resistance is impaired backward displacement of the stomach and the pylorus
by the neuraxial blocks prolongs the gastric emptying time
 supine positioning is avoided during administration of  these physiologic changes put the pregnant woman at risk
regional anesthesia in the second and third trimester for hyperacidity, heartburn, esophagitis, nausea, vomiting and
 significant lateral tilt is frequently used during labor analgesia aspiration and chemical pneumonitis will result to acid
and cesarean section to reduce hypotension and preserve aspiration syndrome of Mendelson, atelectasis, lung abscess,
fetal circulation by displacing the gravid uterus leftward and mechanical obstruction, death
off the IVC A. Anesthetic Implications
 accomplished by placing the patient in left lateral position or  may give non-particulate antacids (Na citrate), H2-receptor
by elevation of the right hip 10-15 cm with a wedge or antagonists (Ranitidine), and a prokinetic drug
blanket (Metoclopramide) prior to delivery to decrease risk of
 gravid uterus can also compress the lower abdominal aorta pulmonary complications
and can cause arterial hypotension  NPO of at least 6-8 hours prior to the procedure
 aortocaval compression can decrease uterine blood and  use of Rapid Sequence Induction (RSI) during general
placental blood flow anesthesia
 prolonged maternal hypotension (more than 25% decrease
for an average patient) for longer than 10-15 minutes can
significantly decrease uterine blood flow which can lead to
progressive fetal acidosis
 the increased venous pressure distal to the level of the caval
compression serves to divert blood from the lower half of the
body via the paravertebral venous complex to the azygous
vein
 dilation of the epidural and paravertebral veins may increase
the rate of intravascular injection of local anesthetics which
can have profound effect on the CVS and CNS with potential Fig. 5: Gastrointestinal Changes in Pregnancy
for complete hemodynamic collapse, seizure and death
 dilation of the the epidural and paravertebral veins also
decreases the epidural and subdural spaces, leading to
RENAL CHANGES IN PREGNANCY
decreased dose of local anesthetic to achieve an effect similar

to non-pregnant patients
filtration rate (90-120 mL/min/1.73 m2) are increased by 50-
 a test dose is administered before giving the whole epidural
60% by the third month of pregnancy and do not return to
anesthetic to decrease the likelihood of an unintended
their pre-pregnant state until 3 months post-partum
intravascular placement or total spinal or epidural blockade
 blood urea nitrogen and serum creatinine values are
decreased by 40-50% in pregnant women
 there is increased aldosterone level which contributes to
increased reabsorption of sodium and water in the renal
tubules, contributing to increased intravascular volume, and
occurrence of edema
 plasma renin activity is increased, as is the renin substrate
angiotensin , to which the pregnant woman has decreased
sensitivity

*Legend: Additional notes – color RED “I can do all things through Christ who strengthens me”. Ph. 4:13 | Page 3 of 10
 CMED 321 LABOR ANALGESIA AND ANESTHESIA
 there is decreased tubular reabsorption of both protein and
glucose leading to proteinuria and glucosuria
 Resulting to glucosuria of 1-10 g/day and proteinuria of <
300 mg/day may not be associated with any pathologic
condition
 renal calyces, pelves, and ureters dilate after the third month
of gestation due to progesterone production which causes
atony of the calyces and ureters
 ureters are compressed by the gravid uterus at the later stage
of pregnancy further contributing to the ureteral dilatation
 resulting dilatation, ureteral atony and stasis contributes to
the frequency of UTI in pregnant women
Fig 6. Renal Changes in Pregnancy
HEPATIC AND ENDOCRINE CHANGES IN PREGNANCY
 liver blood flow does not change significantly with pregnancy
 plasma protein (albumin) level is decreased which lead to an
increased free blood level of high-protein bound drugs
 slightly increased liver function tests (ALT and AST
determination) are common in the third trimester
 serum alkaline phosphatase levels double during pregnancy
(even without underlying hepatic pathology) from placental
production
 plasma cholinesterase activity is decreased about 25-30%
from the tenth week of gestation to 6 weeks postpartum,
leading to decreased metabolism of ester-linked local
anesthetics (prilocaine, tetracaine)
 incomplete gallbladder emptying and changes in bile
composition, making pregnant patients at higher risk to have
cholecystitis/cholelithiasis
 decreased atrial natriuretic peptide (ANP) plasma
concentration resulting to intravascular blood volume is
increased and maintained during pregnancy
 insulin sensitivity is decreased in the second half of
 mild thyroid gland hypertrophy and increased levels of
bound T3 and T4, but the free thyroxine and triidothyronine
remain normal
Fig 7: Hepatic Changes in Pregnancy
*Legend: Additional notes – color RED
NERVOUS SYSTEM PREGNANCY CHANGES IN PREGNANCY
 volatile anesthetic requirement (minimum alveolar
concentration, MAC) is decreased by up to 28% within the
first trimester of pregnancy
 concentration of volatile agents which would not routinely
produce unconsciousness in non-pregnant patients would
approximate anesthetizing concentrations among pregnant
women
 the plasma and CSF levels of progesterone increase during
pregnancy, and this hormone has some sedative activity and
increased nerve sensitivity to local anesthetics
 anesthetic requirements for inhalational anesthetics return to
normal in 3-5 days post-partum with the decreased level of
progesterone
 -endorphin levels in pregnancy also
contribute to a decreased anesthetic requirement
 as a result of increased intra-abdominal pressure, epidural
veins are engorged making accidental intravascular injection
of local anesthetic during lumbar epidural anesthesia more
common, and a decreases epidural space resulting to
decreased dosing of epidural anesthetics
 the increased CSF pressure during labor and bearing down
can produce a rapid upward spread of local anesthetic during
spinal anesthesia
 The approximately 30% reduction of local anesthetics
required during neuraxial block can be attributed to a
number of mechanisms:
A. Swelling of epidural veins can decrease the
CSF volume in the vertebral canal and the
epidural space, resulting to achieving higher
anesthetic block at lower dose or volume
B. Labor-induced increase in CSF pressure can
facilitate cephalad flow of hyperbaric local
anesthetics, thus achieving the desired level of
anesthetic block at lower dose (but CSF
pressure itself remains unchanged during
pregnancy)
C. Increased neurosensitivity to local anesthetics
by the elevated progestrone level
D. Increased lumbar lordosis may also enhance
cephalad flow of local anesthetics placed in the
CSF
Fig. 8: Increased lordosis in pregnancy
Fig. 9: Nervous System Changes in Pregnancy
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 CMED 321 LABOR ANALGESIA AND ANESTHESIA
PHYSIOLOGY OF UTEROPLACENTAL CIRCULATION
 the placenta is the interface of maternal and fetal tissue for
the purpose of physiologic exchange
 maternal blood is delivered to the uterus and placenta by
uterine arteries which divide into spiral arteries in the
placental plate
 blood is spurted from these arteries into the intervillous
space where maternal blood is exchanging substances with
fetal blood within the villi
 nutrient-rich, waste-free and oxygen-carrying blood is
transferred from the placenta to the fetus from the
intervillous space through a single umbilical vein
 fetal blood (low-oxygen tension) returns to the interface with
the maternal circulation (in the placenta) via two umbilical
arteries
Fig. 10: Uteroplacental Blood FLow
A. The Uterine Blood Flow
 UBF increases throughout gestation from about 100 mL/min
before pregnancy to 700 mL/min (about 10% of the cardiac
output) at term gestation
 about 80% of the UBF perfuses the intervillous space
(placenta) and 20% supports the myometrium
 the uterine vasculature has limited autoregulation and
remains essentially maximally dilated under normal
pregnancy conditions
B. Factors that decrease uterine blood flow
 Systemic hypotesnion secondary to:
-Hypovolemia
-Aortocaval compression
-Decreased systemic vascular resistance due to general or
regional anesthesia
 Increased uterine venous pressure secondary to:
-Vena caval compression (supine compression)
-Prolonged or frequent uterine contractions
-Significant abdominal musculature contractions (Valsalva
maneuver [bearing down] or pushing)
 Extreme hypocapnia (PaCO2) associated with
hyperventilation secondary to labor pains can reduce UBF to
the point of fetal hypoxemia and acidosis.
C. The Umbilical Blood Flow
 the umbilical blood flow in the undisturbed fetus at term is
120 ml/kg/min or 360 mL/min
 it is unaffected by acute moderate hypoxia but is decreased
by severe hypoxia
 umbilical blood flow decreases with the administration of
catecholamines or acute cord occlusion
D. Permeability of Placental Membrane
1. Molecular Size
 a molecular weight of 1000 g/mol (Da) is a rough dividing
line between those substances that cross the placenta by
diffusion and those that are relatively impermeable
*Legend: Additional notes – color RED
 if one uses heparin (with a molecular weight of 6000 Da), the
fetus does not get concomitantly heparinized(anticogaulated)
against using warfarin (Coumadin) with a molecular weight of
330 Da, the fetus will be anticoagulated (aside from the
teratogenic effects of coumadin)
2. Lipid Solubility
 a highly-soluble substance easily traverses the placenta and
could get into the fetal circulation
 isoflurane is more lipid soluble than sevoflurane, thus crosses
the placenta more easily
3. Electric Charge
 ionized substances cannot easily cross the placenta
 succinylcholine is poorly diffusible in the placenta despite its
molecular weight of just 361 Da because it is highly ionized,
making it hard for this substance to cross the placenta and
reach the fetus
 local anesthetics (lidocaine) are unionized substances (in an
environment with normal pH) that easily cross the placenta to
reach the fetus and back to the maternal circulation
 in the presence of fetal hypoxia (fetal distress), the fetal
environment because acidic and ionizes the local anesthetic,
making this substance unable to cross the placenta back to
the maternal circulation (fetal ionic trapping) and could cause
a hypotonic neonate on delivery
FETAL CIRCULATION
 the O2-rich maternal blood from the placental villi is
transported from the placenta to the fetus through the single
umbilical vein
 the oxyhemoglobin dissociation curve of the maternal blood
is shifted to the right making oxygen readily available to the
fetus
 the low-oxygen fetal blood is transported from the fetus to
the placenta through the two umbilical arteries, and in the
placenta, this is circulated back to the maternal circulation for
oxygenation
 the low-oxygen fetal blood is transported from the fetus to
the placenta through the two umbilical arteries, and in the
placenta, this is circulated back to the maternal circulation for
oxygenation

oxygenated blood from the placenta away from the
semifunctional liver and toward the heart th
oxygenated blood from the placenta enters the right atrium
via the IVC
 enters the right atrium and mixes with the unoxygenated
blood is pumped from the right atrium partly to the right
ventricle, mostly to the left atrium through the patent
foramen ovale
 from the right ventricle, the blood is pumped to the
pulmonary artery and shunted from the lungs to the aorta
through the patent ductus arteriosus
 from the left atrium, blood goes to the left ventricle and
pumped out of the ventricle to the aorta
 mixed blood is pumped to the different body parts but
mostly brought back to the placenta through the two
umbilical arteries
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 CMED 321 LABOR ANALGESIA AND ANESTHESIA
Fig. 11
 the ductus arteriosus is patent because of the low oxygen
tension in the circulating blood and the action of the
circulating prostaglandins
 NSAIDs are contraindicated in pregnancy because it inhibits
prostaglandin activity necessary to keep the ductus arteriosus
patent
THE FETAL METABOLISM AND EXCRETION OF DRUGS
 human fetal liver microsomes have significant cytochrome-P
(CYP) levels and NADPH cytochrome C-reductase as early as
the 14th week age of gestation, suggesting that even
premature fetuses can metabolize numerous drugs, including
most local anesthetics
STAGES OF LABOR AND LABOR PAINS
A. 1st Stage of Labor (Cervical Dilatation)
 from onset of labor to full cervical dilatation
 Latent Phase is from 1-4cm cervical dilatation
 Active Phase is from 5cm to fully dilated (10 cm) cervix
 pain in the first stage of labor comes as a result of afferent
nerve impulses from the lower uterine segment and the
cervix, with contributions from the contracting uterine body
causing visceral pain (poorly localized, diffused but intense
aching)
 the afferent nerve impulses pass through the paracervical
tissue and course with the hypogastric nerves and the
sympathetic chain to the dorsal root ganglia of levels T10 to
L1.
Fig. 12: Innervation of Labor Pains
*Legend: Additional notes – color RED
B. 2nd Stage of Labor (Pushing and Expulsion)
 starts from a fully dilated cervix (10 cm) to fetal expulsion
 during this stage of labor, the afferents innervating the
vagina and perineum cause somatic pain (well-localized and
sharp)
 the impulses travel primarily via the pudendal nerve to dorsal
root ganglia of levels S2-S4
 pain during this stage is also caused by distention and tissue
ischemia of the vagina, perineum and pelvic floor
LABOR ANALGESIA
A. Non-pharmacologic Techniques
1. Lamaze Method
 developed by French Obstetrician in the 1950s
 focus was on use of controlled breathing techniques to cope
with labor and labor pains
 other relaxation techniques and natural startegies to help
work with labor pains, such as massage, walking , position
changes and hydrotherapy
 partner is present during labor to help with the relaxation
techniques and encourage the parturient
 most non-pharmacologic techniques seem to reduce labor pain
perception but lack the rigorous scientific method for useful
comparison of these techniques to pharmacologic methods
 a woman‟s satisfaction with labor and delivery may not be directly
associated with analgesia efficacy
B. Systemic Medications
 systemic analgesics are utilized on labor and delivery
 usually utilized during the early stage of labor or towards or
after delivery
 use of systemic opioid analgesics (nalbuphine, fentanyl,
meperidine) is quite common, but the use of sedatives
(propofol), anxiolytics (benzodiazepines) and dissociative
drugs (ketamine) is rare
1. Opioids
 all opioids readily cross the placenta and exert neonatal
effects, including decreased fetal heart rate variability and
neonatal respiratory depression
 maternal effects include nausea, vomiting, pruritus and
prolonged gastric emptying time
 the potential for maternal sedation, respiratory compromise,
loss of airway protection, and proximity to time of delivery
dictate judicious use of opioids
 for women who are in early stage of labor, systemic opioid
analgesia can be beneficial
C. Neuroaxial Analgesia
 administration of either local anesthetics or opioids or a
combination of both either in the epidural space (epidural
anesthesia) or in the subarachnoid space (spinal anesthesia)
1. Local Anesthesia (LA)
 drugs that produce reversible conduction blockade of
impulses along central and peripheral nerve pathways
 can produce autonomic nervous system blockade, sensory
anesthesia and skeletal muscle paralysis
 block transmission of nerve impulses by reversibly binding
with the intracellular portion of the voltage-gated Na+-
channel
 either ester-linked (procaine, tetracaine) or amide-linked
(lidocaine, bupivacaine, ropivacaine)
 ester-linked LA are metabolized by plasma cholinesterase,
decreasing the risk of maternal toxicity and placental drug
transfer
 amide-linked LA are degraded by P-450 enzymes in the liver
 accidental large intravascular dose of any local anesthetic can
result in significant maternal morbidity (seizures, loss of
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 CMED 321 LABOR ANALGESIA AND ANESTHESIA
consciousness, severe arrhythmias, cardiovascular collapse) or
fatality and potential for fetal accumulation of LA (ion
trapping)
2. Opioids
 commonly used to augment the neuraxial analgesia of LA
(commonly used are the highly-lipid soluble fentanyl and
sufentanyl)
 administration of opioids alone in the subarachnoid/epidural
spaces can provide moderate analgesia but are not as
effective as dilute LA
 act on different opioid receptors in the spinal cord
 See Appendix for Classification of Opioids Recepetors
D. Neuroaxial Techniques
 represent the most effective form of labor analgesia and
achieve the highest rate of maternal satisfaction
 ADVANTAGES
a. the patient remains awake and alert without
sedative side effects
b. maternal catecholamine concentrations are
reduced
c. hyperventilation is avoided
d. cooperation and capacity to participate actively
during labor and delivery are facilitated and excellent
e. predictable analgesia can be achieved
f. analgesic effect provided is superior to all other
techniques
1. Preoperative Assessment and Preparation
 get patient‟s pregnancy and health history
- OB score, last oral intake, previous
surgeries, medical illnesses
 do fast but pertinent physical exam
- airway assessment, build and size of
patient, assess cardiopulmonary functions
(murmur, dyspnea, signs of congestion,
edema)
 prepare patient monitors
- cardiotocogram, BP apparatus, cardiac
monitors, pulse oximeter
 prepare anesthetic needs
- epidural/spinal set, desired medicines,
resuscitation drugs and equipments
3. Timing of Neuroaxial Blockade
 it has been recommended by ASA and ACOG that a
maternal request for labor pain relief is sufficient
justification for epidural placement, and decision
should not depend on arbitrary cervical dilatation
4. Epidural Anesthesia
 catheter-based technique used to provide continuous
pain relief during labor
 the technique involves insertion of a specialized
(Tuohy) needle into the epidural space normally
inserted between L2 and L4 interspace
 the parturient may either be in lateral or sitting position
depending on both the experience of the
anesthesiologist and the need to optimal exposure of
critical anatomic landmarks
 aseptic technique should always be carried out during
the placement of neuraxial needle and catheter to
avoid iatrogenic CNS infection
 the tip of the Tuohy needle should not penetrate the
dura mater
 to locate the epidural space, a tactile technique called
the loss of resistance is used
 the tactile resistance noted with pressure on the
plunger of an air-filled syringe dramatically decreases
as the tip of the needle is advanced through the
*Legend: Additional notes – color RED
ligamentum flavum (dense resistance) into the epidural
space (no resistance)
 the epidural space is approximately 5 cm deep from
the skin
 once the needle is properly placed, a catheter is
inserted through the needle
 the catheter remains in the epidural space and the
needle is removed
 the catheter outside of the epidural space is then
secured on the patient‟s back with a tape, and the port
with filter is placed at the tip of the catheter
 once the catheter is in place, a “test dose” is
administered by giving small amount of LA admixed
with epinephrine
 test dose is done to avoid accidental intravascular
injection of high dose of LA
 also to avoid giving high dose and volume of local
anesthetic in the subarachnoid area (which may result
to total spinal block) in case there is catheter migration
to the subarachnoid area
 if the epidural anesthesia is placed during the early
stage of labor, anesthetic block should cover up to the
level of T10 to provide adequate analgesia
 in the advanced stage of labor, the block should cover
pain conducted via the S2-S4 nerve root, thus a need
for higher volume of local anesthetic since the sacral
vertebra is bigger than the lumbar area
 dosing of epidural anesthetic is volume-dependent
more than its desired dose
 to achieve adequate block, LA is given in diluted form
so higher volume can be given without reaching the
toxic doses of the LA
 opioids are also added to the LA to provide additional
analgesia and at the same time reduce the required
dose of local anesthetic while giving adequate
analgesia
 this technique is used for labor analgesia, anesthesia
after fetal delivery or for an emergency cesarean
section should their be any indication
5. Spinal Anesthesia
 this technique is useful for advanced stages of labor
(usually just before vaginal delivery), assisted delivery
(outlet forceps extraction), evaluation/evacuation of
retained placenta, or repair of high-degree perineal
laceration
 “low-spinal” block or “saddle block”
 low-dose hyperbaric bupivacaine is given with or
without additional opioids
 LA can be given either in lateral position or sitting
position
 also used in case of an emergency cesarean section
should there be any indication
 low-dose hyperbaric bupivacaine is given with or
without additional opioids
 LA can be given either in lateral position or sitting
position
 also used in case of an emergency cesarean section
should there be any indication
 low-dose hyperbaric bupivacaine is given with or
without additional opioids
 LA can be given either in lateral position or sitting
position
 also used in case of an emergency cesarean section
should there be any indication
6. Contraindications of Neuroaxial Techniques
 Patient refusal
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 CMED 321 LABOR ANALGESIA AND ANESTHESIA
 Infection at site of needle injection
 Significant coagulopathy
 Hypovolemic shock
 Increased intracranial pressure from mass lesion
 Inadequate experience of the Anesthesiologist
E. Complications of Neuroaxial Techniques
1. Systemic Toxicity and Excessive Blockade
 infrequent but usually fatal complication of neuraxial
anesthesia
 the most serious complications are from accidental IV or
intrathecal injection of high dose of local anesthetics
 complications are dose-dependent ranging from minor side
effects (ex. Tinnitus, perioral tingling, mild hypotension and
bradycardia) to major complications (ex. seizure, loss of
consciousness, severe arrhythmias and subsequent
cardiovascular collapse)
 severity of complications depend on the dose give, type of
local anesthetic given and presence of co-existing medical
problems
 bupivacaine has greater affinity for sodium channel than
lidocaine and dissociates more slowly, plus its high protein
affinity, making cardiac resuscitation more difficult and
prolonged
 once the LA has reached the fetus and fetus is hypoxemic and
acidotic, there will be “ion trapping” of the LA in the fetal
circulation which could lead to neonatal seizures post-
delivery
 to avoid this complication, always do test dosing and give
low/diluted and incremental doses of LA for epidural
anesthesia
 treatment and management for this complication are
directed to restoring maternal and fetal oxygenation,
respiration and circulation
 vasopressors, fluid infusion, intubation and ACLS protocol (if
needed)
 immediate delivery of the baby if the mother is not
resuscitated within 4 minutes
2. Hypotension
 defined as a decrease in blood pressure > 20%
 this is the most common complication of neuraxial blockade
for labor analgesia
 prophylaxis can be done by judicious fluid infusion and left
lateral tilt
 vasopressors are given to facilitate vasoconstriction in order
to restore normotension
 Ephedrine (primarily - -
adrenergic activity) is the usual drug used to restore BP to
normal state
 IV administration results in increases in systolic and diastolic
blood pressure, heart rate and cardiac output
 uterine blood flow is not greatly altered when ephedrine is
used to restore maternal blood pressure to normal following
sympathetic blockade

the same time decreases uterine blood flow because of
vasoconstriction
3. Shivering
 may occur after neuraxial anesthesia due to heat loss by
dilating blood vessels in the skin
 Meperidine is usually used to decrease shivering by lowering
the body‟s shivering threshold and due to its activity in the
kappa opioid receptor
F. Paracervical Block
 infrequently used to provide pain relief during the first stage
of labor
*Legend: Additional notes – color RED
 there is submucosal administration of local anesthetic
immedately lateral and posterior to the uterocervical junction,
which blocks transmission of pain impulses at the
paracervical ganglion
G. Pudendal Block
 infrequently used to provide pain relief in the second stage of
labor
 used in hospitals when neuraxial block is unavailable
 local anesthesia injected around the pudendal nerve blocks
sensation of the lower vagina and perineum
 although it may provide analgesia when successful, the failure
rate of this technique is high
ANESTHESIA FOR CESAREAN SECTION
A. Indications for Cesarean section
 non-reassuring fetal status
 dysfunctional labor
 medical conditions
B. CHOICE OF ANESTHESIA:
 indications of doing CS
 medical condition of the parturient
C. General Anesthesia
 done using the rapid sequence induction because all
pregnant patients are always considered to have full stomach
 laryngoscopy and endotracheal intubation always anticipated
to be difficult because of airway edema and morbid obesity
of some parturients
 approximately 2/3 of deaths associated with general
anesthesia were related to induction problems or intubation
failure
 before induction of anesthesia, the whole surgical team is
already prepared to start with the surgery immediately after
the Anesthesiologist deems safe to start
 all apparatus needed to secure the airway should be readily
available prior to induction
 functional laryngoscope and endotracheal tubes of different
sizes (usually smaller ones)
 the Anesthesiologist should also be aware of the Difficult
Airway Protocol
1. Propofol
 highly-lipid soluble drug that results in rapid onset and short
duration of action that renders the patient unconscious in
less than 30 seconds
 has no significant neonatal outcome at induction dose 2.5
mg/kg but is associated with neonatal depression at higher
dose (9 mg/kg)
2. Ketamine
 produces rapid onset of anesthesia, but unlike Propofol,
Ketamine‟s sympathomimetic characteristics increase arterial
pressure, heart rate and cardiac output by stimulation of the
sympathetic nervous system
 dissociative anesthesia (causes “bad dreams”), and its “bad
dreams” effects can be lessened by coadministration of
benzodiazepines
 because of its sympathomimetic effect, this is the ideal
anesthetic for patients who are hemodynamically
compromised (parturient with active bleeding, hemorrhaging
and has uncertain blood volume and is at risk for
hypotension)
 doses above induction dose (1-1.5 mg/kg) can increase
uterine tone, reduce uterine artery perfusion, and cause fetal
hypoperfusion
3. Benzodiazepines (Anxiolytics)
 rapidly crosses the placenta and can cause neonatal
respiratory depression and neonatal hypotonia
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 CMED 321 LABOR ANALGESIA AND ANESTHESIA

 may be given in low doses to benefit from its amnesic effect

4. Succinylcholine
 neuromuscular blocking agent of choice for obstetric patients
because of its rapid onset and short duration of action
 because it is highly ionized and poorly lipid soluble, only very
small amount crosses the placenta
 it is normally hydrolyzed in the maternal blood by the
enzyme pseudocholinesterase and does not generally
interfere with fetal neuromuscular activity
5. Rocuronium
 alternative to succinylcholine because of its rapid onset of
action providing adequate intubating condition in less than
90 second at a dose of 0.6 mg/kg
 it has longer duration of action making it difficult for the
Anesthesiologist to extubate the patient after the procedure,
but can be reversed using sugammadex
 this drug is poorly lipid soluble and poorly ionized making it
difficult to cross the placenta to cause neonatal muscle
weakness
 but when given at higher dose over a longer period of time,
it may cross the placenta resulting to a paralyzed neonate
 a paralyzed neonate will present with normal cardiovascular
function and good color but no spontaneous respiration, no
reflex responses and skeletal muscle flaccidity
 Treatment: full respiratory support until the neonate excretes
the drug which may take 48 hours
6. Inhalation Anesthetics
 inhalational anesthetics are used to maintain anesthesia
during CS
 this is given at low concentration (< 0.75 of MAC) of volatile
anesthetic
 placental transfer of volatile anesthetic is rapid because they
are non-ionized, highly lipid soluble substances of low
molecular weight
 a depressed fetus is likely to be associated with a depressed
neonate
 if the neonate is depressed because of the effect of the
inhalational anesthetic, the neonate needs adequate
ventillatory support to facilitate elimination of the
inhalational anesthetic
 rapid improvement of the neonate is expected, and if the
neonate remains depressed, other causes should be
investigated
 can also cause dose-related uterine relaxation and atony
which may lead to profuse maternal bleeding
 also has negative effect on the efficacy of oxytocin in causing
uterine contractions
 also has negative effect on the efficacy of oxytocin in causing
uterine contractions
 can be used in some uncommon situations where uterine
relaxation is indicated rather than being hazardous:
 internal podalic version of the second twin in breech
presentation, breech decomposition, replacement of acutely
inverted uterus

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 CMED 321 LABOR ANALGESIA AND ANESTHESIA

*Legend: Additional notes – color RED “I can do all things through Christ who strengthens me”. Ph. 4:13 | Page 10 of 10