In The Name of GOD

M. A. Attari, MD.Associated Professor of Anesthesiology

Medical University Of Isfahanma_attari@yahoo.com

Obstetric analgesia for normal delivery and anesthesia methods for

Cesarean section in Isfahan-IRAN

In our province approximately 60% of parturient get delivery by cesarean section, while in the our country as a whole is 46% and in south east of IRAN in Zabol near to the Pakistan is about 4%.

The usual methods of analgesia for Vaginal Delivery is:

o Inhalation analgesia

o Systemic narcotics

o Tranquilizers / hypnotics

o Acupuncture

o TENS

o Psychoanalgesic techniques

TECHNIQUES OF LABOR ANALGESIA

• Continuous epidural analgesia • Patient-controlled epidural analgesia (PCEA)• Combination of the above two techniques• Combined spinal-epidural analgesia (CSE)• Spinal opiates• Intermittent epidural bolus injections

Inhalation Analgesia for Vaginal Delivery

Advantages:

Easy to administer (no needles or PDPH)

“Satisfactory” analgesia variable

Minimal neonatal depression

(N2O 30-50%; very low concentration volatile agents )

Inhalation Analgesia for Vaginal Delivery

Disadvantages:

Decreased uterine contractility (except N2O)

Rapid induction of anesthesia in pregnancy

Risk of unconsciousness and aspiration

Difficulties with scavenging in labor rooms

(N2O 30-50%; very low concentration volatile agents )

Pain Intensity with and without Entonox

Pain Relief percentage

Pain Intensity

Analgesia for Labor and Delivery

• Local infiltration

• Pudendal block

• Paracervical block

• Paravertebral (lumbar sympathetic block)

• Epidural - lumbar (caudal)

• Spinal

• Combined spinal-epidural (CSE)

Local and regional techniques

Continuous Infusion Epidural

A larger volume of a more dilute agent is more effective

for labor analgesia than a smaller volume of higher

concentration

PCEA• Good analgesia• Patient autonomy• Less need for MD interventions• Cost effective

Strategies to Decrease Complications with CSE

• Decrease dose of opioid:– Fentanyl 15-20 µg– Sufentanil 2.5-5 mg

• Combine with:– Local anesthetic (bupivacaine 1.25-2.5

mg)– Epinephrine

Controversial Areas

• Effects on labor and delivery process

• Maternal temperature elevation

• Drug choice - are new agents better?

• Epidural vs. CSE

LOCAL ANESTHETICSContinuous infusion:Bupivacaine 0.0625%-0.25%-8 -15 ml/hrRopivacaine: 0.125%-0.25%- 6 -12 ml/hrLidocaine: 0.5%-1% -8-15 ml/hr2-chloroprocaine 0.75% -27 ml/hrIntermittent bolus injections:Bupivacaine: 0.125%-0.375%, 5-10 ml, duration:1-2 hrRopivacaine: 0.125%-0.25%, 5-10 ml, duration: 1-2 hrLidocaine: 0.75%-1.5%, 5-10 ml, duration: 1-1.5 hr2 chloroprocaine 1-2%, 5-10 ml, duration: 0.75-1 hr

EPIDURAL ANALGESIA

• Disadvantages:• Not instant in onset• May be associated with motor block• Postdural puncture headache (50-85% with 16 or 18-

G Tuohy’s needle)

LEVEL OF BLOCK

• High Level: Can result from high dose or subdural/subarachnoid migration of catheter

• Low level: Can result from intravenous migration of catheter, catheter outside the epidural space or administration of inadequate dose of local anesthetic

CONTINUOUS EPIDURAL INFUSION

Still used routinely at many centersGood pain reliefLess motor blockMaternal and neonatal drug concentrations safe if

used cautiouslyWe routinely use either 0.0625% bupivacaine+fentanyl 2.5 μg/ ml at 12

ml/hr (early labor)+demand dose: 4 ml q 15 min0.125% bupivacaine+fentanyl 2 μg/ml at 8 ml/hr

(advanced labor)+ demand dose : 3 ml q 15 min

PATIENT CONTROLLED EPIDURAL ANALGESIA

• Advantages:• Flexibility and benefit of self administration• Ability to minimize drug dosage• Reduced demand on professional time• Disadvantages:• May provide uneven block• Addition of a basal infusion provides:• More even block producing greater patient

satisfaction

Are We Doing Enough?• Facemasks• Prep solution (Betadine)• Gloves• Bacterial Filter• Filtered Needle

Hand Care

• Washing with alcohol based solution

• Artificial nails – Gram-negative

pathogens on their fingertips

• Jewelry– Areas under rings more

heavily colonized that comparable areas

Conclusions

• Individualize technique to patient’s goals

and stage of labor

• Optimize management for spontaneous

delivery

• Provide safe, cost-effective analgesia

Point