Anesthesia for the Obstetrical Patient

Fred Rotenberg, MD Dept. of Anesthesiology Rhode Island Hospital

Grand Rounds February 27, 2008

Anesthesia for the Obstetrical Patient

The Pregnant Patient for Nonobstetric Surgery

LABOR DELIVERY OBSTETRICAL EMERGENCIES SPINAL HEADACHES AND BLOOD PATCHES

Alterations in Maternal Physiology

Respiratory

Increased O2 consumption Decreased FRC and pCO2 (increased MV)

Increased blood volume and CO Dilutional anemia Possible aorto-caval compression (when supine) Reduced gastroesophogeal tone

Cardiovascular

GI

Reduced anesthetic requirements (both GA & regional)

Anesthesia for the pregnant patient undergoing non-obstetric surgery

THE OBVIOUS
AVOID

MATERNAL HYPOXIA AND HYPOTENSION

THE NOT SO OBVIOUS

Prevention / Treatment of preterm labor

Probably NOT related to anesthetic management Due to SURGERY and/or underlying pathology Tocolytics (indocin or MAGNESIUM, hi dose volatile anesthetics)
Benzodiazepenes? Nitrous oxide? NO GOOD EVIDENCE re: risk in humans

Teratogenic effects of anesthetics

THE NOT SO OBVIOUS - continued

Dose dependent effect of general anesthetics on fetal or newborn animals Apoptotic neurodegeneration Persistent memory/learning impairments

Therefore: USE AS LITTLE GENERAL ANESTHETIC (iv and volatile) as possible

Things we can (& should) do:

If possible delay surgery til 2nd trimester

Less risk of teratogenicity, miscarriage, than 1st trimester preterm labor more likely in 3rd trimester

Left uterine displacement after 24th week Consider aspiration prophylaxis; midazolam (reduce maternal stress ->improve fetal blood flow) Consider Fetal monitoring (but no good data) Consult with obstetrician

ANESTHETIC CHOICES

GA-preoxygenate, rapid sequence induction, slow reversal of relaxants, +/N2O

Loss of beat to beat FHR variability is normal; Fetal bradycardia is not!

Regional anesthesia-minimal effects on fetus (assuming normal BP)

Cut neuraxial dose of local anesthetic by 1/3rd compared to non-pregnant patient

NO evidence showing better outcome

POST - OP
Continue fetal monitoring Because of risk of thromboembolism:

Early mobilization Consider anticoagulants Post op analgesia (regional is good at this)

LABOR ANALGESIA
Intravenous Neuraxial: Epidural Spinal Combined Spinal-Epidural

Goals of Labor Analgesia

Adequate Analgesia Allow the mother to participate in birthing experience Minimal effect on the fetus Minimal effect on the progress of labor

Neuraxial Blockade
A well conducted block provides the most effective and least depressant analgesic Spinal opiate (single shot) fast onset, limited duration Continuous Epidural slower onset, but duration is adjustable. Potential motor block. Combined Spinal Epidural best of both

Arguments for epidural for Labor

Relative risk of maternal mortality during C-section was 16x greater with GA compared to regional anesthetic

Epidural for labor is now used in ~2.4m of the 4m total births in the US per year

Arguments against epidural for Labor

Incidence Incidence Incidence ~ 1/237k 1/5,500)

of epidural infection ~ 1/145k of Epidural bleed ~ 1/150-170k of persistent neurological injury (transient neurologic injury ~

Still about 20% of pts w/ labor epidural require conversion to GA for C-section

Disadvantages of epidural analgesia for labor

Slows labor by approximately one hour Questionable effect on Cesarean Section delivery rate Increases use of instruments during vaginal delivery Increased incidence of maternal fever (and subsequent fever workup of mom and child)

Effect of Early Neuraxial Analgesia on C-Section Rate

Many older studies show no clear difference in section rate comparing neuraxial and parenteral opiate analgesia.

Wong et al. NEJM 2005 Prospective demonstrates no increase in C-section rate comparing early vs later epidural opiate administration.

Epidural analgesia increases rate of instrument assisted deliveries

Rate of instrument assisted vaginal deliveries is at least doubled by epidural analgesia Etiology of this effect?

Motor block from neuraxial local anesthetic Epidural analgesia is associated with increased rate of occiput posterior presentation (does this painful presentation promote increased demand for epidural analgesia?) The presence of a block might lower obstetricians threshold for using instruments

LABOR EPIDURAL
Continuous combined dilute local anesthetic plus opiate. Better pain relief when combined; less motor block. Less instrumented deliveries. Minimal absorbtion by Mom or baby.

Eg: Bupivicaine 0.0625% plus 2ug/ml

fentanyl (+/- epinephrine) @ 10-12 ml/hr.

Notes on epidural cath placement

Sterile technique Loss of resistance to fluid (not air) Prevent intrathecal placement (0.5-3% incidence) Prevent intravenous placement (3-15% incidence) (use Arrow Flex-Tip; inject 10 ml dilute local through needle prior to cath placement). Aspiration of blood or csf is quite reliable

Notes on epidural cath placement - 2

Epinephrine test dose is not sensitive for intravenous location.* Local anesthetic (eg 45mg of Lido w/ epi) as test for intrathecal placement is somewhat better.

Wait 5 min after test to see motor changes. Seek subjective change in pts ability to feel normal contraction of muscles controlling micturation. Rapid profound analgesia suggests intrathecal dose.

Notes on epidural cath placement - 3

Safety is determined by the above careful placement AND DOSE FRACTIONATION give 3ml every 1-2 minutes. patience is wisdom and wisdom is patience

Notes on epidural cath placement -4

For a wet tap consider: Thread the epidural cath intrathecally and use it for continuous spinal. (Then leave it in place for 24 hrs to reduce the risk of spinal HA.) Spinal catheter dosing: Bupiv 0.1% plus sufentanil 0.5ug/ml. Start with 3 ml bolus; infuse a basal rate of 2 ml/hr; allow PCEA boluses of 1 ml q 30min prn.

Combined Spinal Epidural Analgesia

Most beneficial in early or late labor (especially the multiparous patient) #27 spinal needle through epidural needle followed by epidural catheter insertion Almost immediate pain relief with spinal opiate (fentanyl 10-25ug or sufentanil 2.5-10ug) 2-3 hour duration of analgesia with the spinal opiate Patient may ambulate

Combined Spinal Epidural Analgesia

In early labor (<4 cm dilation) CSE promotes more rapid cervical dilation than IV hydromorphone. Also, high concentrations of local anesthetic slow labor.

Combined Spinal Epidural Analgesia

For severe pain in the late stages of labor may need to add local anesthetic to spinal mixture. Rx Sufentanil 2.5-5ug plus bupivicaine 2.5 mg -> Rapid profound analgesia without significant motor block. Longer duration of analgesia than opiate alone.

Problems with Intrathecal Opiates

Pruritus usually mild and short lived Nausea and vomiting best treatment? Hypotension Rx ephedrine. Urinary retention Uterine hyperstimulation and fetal bradycardia? (studies show no increased risk) Maternal respiratory depression monitor for at least 20 minutes post injection

Technical Problems with CSE

Post dural puncture headache (Incidence is 1% or less)

Subarachnoid migration of epidural catheter? Risk is remote especially with separate port in epidural needle for spinal needle. Still use small incremental epidural doses

Patient Controlled Epidural Analgesia

May minimize drug doses, less motor block, but may provide inferior analgesia should we add a basal infusion rate (69ml/hr)? Must set limits to bolus doses. (4-6ml q 510min; max 4-6doses/hr) Although less demands on anesthesia personnel, must still make periodic assessments.

Continuous Spinal Analgesia?

Microcatheters are they associated with cauda equina syndrome? 28g microcatheters seem safe (Arkoosh et al 2003) but are still not FDA approved. Clearly increased risk of headache with larger catheters, but advantage of controlled incremental dosing (cf epidural) may justify its use.

Anesthesia for delivery Vaginal

Epidural Perineal dose for imminent delivery (10-12 ml of 0.062%bupiv + 50100ug of fentanyl) to allow the pt to push For forceps delivery or episiotomy repair: epidural 8-12 ml of 2% lido.

Anesthesia for delivery (Cesarian)

GETA Spinal Epidural CSE

Regional anesthesia for C-section

Supplementation of Indwelling Epidural: 10-15ml of 1% lido or 0.125% bupiv, ropiviacaine or levobupivicaine.

Spinal (fast onset, dense block)

Spinal
Fast onset; profound anesthesia; avoid airway risks associated with GA Recipe:Bupivicaine 6-12mg + 0.1mg MS or 20ug fentanyl (setup in 5 min; 2-4 hr duration) Acute Hypotension prevention> 10001500ml crystalloid immediately before spinal; left uterine displacement. Tx of hypotension: Ephedrine (10mg) +/phenylephrine

Post Dural Puncture Headache

Caused by decreased ICP, cerebral vasodilation Dx: Postural component and cervical muscle spasm Not always self limited, not always benign

Abducens N. palsy (visual problems) Auditory disturbances Subdural hematoma / hygroma

blood patch

Autologous blood patch is warranted

Risk is small Effective

Avoid in coagulopathy or febrile patient Keep pt recumbent for 2 hrs after patch Pts should avoid heavy lifting or Valsalva Rx: stool softener and/or cough suppressant Prophylactic blood patch is not warranted (blood patch is less effective if done in 1st 24 hours)

ASA Guidelines
Fetal Heart Rate monitoring before and after labor epidural For elective cases, clear liquids acceptable up to 2 hrs preop; no solids for 6-8 hrs. Timely administration of non-particulate antacids, H2 blockers and/or metoclopramide. Pencil point spinal needles should be used rather than cutting needles to reduce PDP headache

ASA Guidelines - 2
For urgent delivery GA is faster than SAB which is faster than epidural GA is associated with lower APGAR scores Phenylephrine for maternal hypotension may cause less fetal acidosis than ephedrine infusions. Cell saver should be considered for massive hemorrhage

ASA Guidelines - 3
Labor/delivery units should be equipped with difficult airway, fluid resuscitation and ACLS equipment For maternal cardiopulmonary arrest (>4 min) consider emergent operative delivery of the fetus in addition to maternal resuscitation Uterine displacement improves maternal venous return and should be routinely utilized

Anesthetic Management for Obstetrical Emergencies

Nonreassuring Fetal Heart Rate (ie Fetal Distress)

FHR deceleration related to uteroplacental insufficiency. Prolonged / repeated deceleration of FHR may lead to fetal acidosis. Lack of fetal heart rate variability may be due to fetal hypoxemia.

Nonreassuring Fetal Heart Rate (ie Fetal Distress)

Profound variable or late decelerations especially if associated with decreased FHR variability dictates consideration of immediate delivery. Fetal pulse oximetry, used in conjunction with FHR monitoring decreases emergent C-section rate related to nonreassuring FHR.

PLACENTAL ABRUPTION
Premature separation of normally implanted placenta May occur pre- or intrapartum (incidence ~ 1:80 deliveries) Associated with maternal hypertension, heavy EtOH use or cocaine use. Leads to maternal blood loss, neonatal neurologic damage or asphyxia

PLACENTAL ABRUPTION
May lead to consumptive coagulopathy and progress to DIC. For suspected abruption type and crossmatch blood; send H/H, plt count, fibrinogen and FSPs For severe abruption consider immediate C-section under GA. Consider oxytocin and other uterotonic drugs and aggressive transfusion.

PLACENTA PREVIA
Abnormal implantation of placenta close to or over the cervical os. Incidence: 1:200-250 deliveries (more common in multipara, prior C-section or previous placenta previa). Common cause of 3rd trimester bleeding For ongoing bleeding may require Csection

UTERINE RUPTURE
Often related to previous uterine scar from previous C-section Sx: Vaginal bleeding, severe uterine pain, shoulder pain, disappearance of FH tones, hypotension. Requires urgent delivery and abdominal exploration.

VBAC

In a prospective study between 1999-2002 ~18k women attempted VBAC; ~16k had elective repeat C-section Symptomatic uterine rupture occurred in 124 (0.7%) of VBAC women Hypoxic-ischemic encephalopathy occurred in 12 infants in VBAC cases; none in elective section Lower incidence of maternal complications in elective section

POST PARTUM HEMORRHAGE

Retained placenta

Occurs in about 1% of deliveries Requires manual exploration of uterus 1 MAC of GA provides uterine relaxation NTG (100 ug) also provides uterine relaxation

POST PARTUM HEMORRHAGE -2

Uterine Atony Seen following 2-5% of deliveries Associated with over distention of uterus, retained placenta, excessive oxytocin use during labor, and operative interventions. Rx: Fluids, uterine massage and uterotonics.

THE END
THANKS FOR YOUR ATTENTION!