Anesthesia and Analgesia in

Obstetrics

Obstetric Analgesia
Non pharmacological method (psychoprophylaxis,
Transcutaneous Electric Nerve Stimulation)
Systemic opioid analgesia
Inhalational agent (entonox)
Analgesia for vaginal delivery (local infiltration,
pudendal block, saddle block)
Patient Controlled Analgesia
Regional analgesia (spinal, epidural, Combined
Spinal Epidural analgesia)
GA for LSCS

Commonly used sedatives/analgesics

in labour
Opioid:
Pethidine (most common)
- Dose:50-100mg IM/IV at start of active phase
(cervix 4cm dilated)
- Delay gastric emptying, aspirationmetoclopramide/ promethazine
- Respiratory depression in neonate- 0.1mg/kg IV
naloxone, bag and mask ventilation

 Fentanyl -1mcg/kg IM/slow IV/infusion

- Cross placenta but not affect APGAR score
- Onset: 2-3min(IV), 10min(IM); last for 30-60min
Tramadol 1-2mg/kg
Onset:15min; last for 2-3hr
Nalbuphine - 10mg IM/IV
Morphine 10mg IM

Inhalational agents
50:50 mixture of oxygen and nitrous oxide
(entonox)
- Analgesic at subanaesthetic conc., 5-6 breaths
sufficient to provide analgesia during a contraction
(not interfere uterine contraction& APGAR score)
- Through demand valve via mouthpiece/ face
mask & deliver a peak inspiratory flow of at least
25L/min; deep breath before contraction & stop
when contraction over
- If conc persistent hyperventilation
decrease oxygen supply to fetus (however gas
elimination is fast, overall effect is small)

Regional analgesia- spinal/epidural

Bupivacaine 0.0625-0.125%; 0.5% for anaesthetic
Ropivacaine
Levobupivacaine
Bupivacaine + opioids(fentanyl 0.2mcg/mL)
LSCS: 2% lidocaine with epinephrine and 3%
chloroprocaine
- very high sensory to motor block ratio
- Opioid addition quicken the onset
- Analgesia maintenance: manual intermittent
boluses/ controlled infusion/ Patient Controlled
- Epidural bolus of 100mcg/mL local anaesthetic can
be of value in 2nd stage of labour

Non pharmacological method

Psychoprophylaxis/ Lamaze technique
Antenatal period:relaxation& breathing exercise
Preparing the woman, allaying her fear,
distacting her from pain
Useful early in labour, questionable in late
labour

Transcutaneous Electrical Nerve Stimulation

(TENS)
Apply variable electrical stimulus to skin at
site of pain
Ideal for woman c/o blackache in early stage
of labour

NERVE SUPPLY OF FEMALE

GENITAL TRACT
Can be divided into external
genitalia and internal genitalia

EXTERNAL GENITALIA
External genitalia is also known as the vulva or
pudendum
It includes the following: mons pubis, labia
majora, labia minora, hymen, clitoris,
vestibule, urethra, Skenes glands, Bartholin
glands and vestibular glands.

 Boundaries:
1.)Anteriorly: Mons pubis
2.)Posteriorly: Rectum
3.)Laterally: Genitocrural fold

NERVE SUPPLY
Through bilateral spinal somatic nerves
Anterosuperior part:
1.)cutaneous branch of ilio ingunal
2.)genital branch of genito femoral
Posteroinferior part:
1.)pudendal branches of posterior cutaneus
nerve of thigh
Between these two groups,the vulva is supplied
by labial and perineal branches of pudendal
nerve.

INTERNAL GENITALIA

NERVE SUPPLY
Vagina: sympathetic and parasympathetic nerves from
pelvic plexus. The lower part is supplied by pudendal
nerve
Uterus: principally from sympathetic and partly from
parasympathetic.
- Sympathetic components are from T5 to T6 (motor)
and T10 to L1 spinal segments (sensory).The abdomen
area, supplied by T10 to L8 corresponds to somatic
distribution of uterine pain.
- The parasympathetic system is represented on either
side by the pelvic nerve which consists of both motor
and sensory fibres from S2,S3,S4 and ends in ganglia of
Frankenhauser.

 Fallopian tube:derived from ovarian and

uterine arteries
Ovaries:Sympathetic supply comes down
along the ovarian artery from T10 segment

Epidural Analgesia
Provide lumbar and sacral analgesia with
minimal motor blockade.
Usually initiated at the onset of active phase
of labour. The patient will appreciate a sense
of giving birth without pain during
contractions
Beneficial in cases like PIH, breech
presentation, multiple gestations and preterm
labour

Contraindications
Maternal coagulopathy or on anticoagulant
therapy
Supine hypotension
Hypovolemia
Neurological diseases
Spinal deformity
Skin infection at injection site

Technique
1. Patient lies on her side and her back is
aseptically prepared.
2. A needle is used to create a lumbar puncture
at L1, L2 into the epidural space.
3. A plastic catheter is passed via a needle and
kept in there, taped to the back for continued
analgesia. Bupivocaine 0.125% + fentanyl
0.2g/ml is recommended.

Complications
Slow onset of analgesia
Patchy analgesia if solution does not spread
evenly in the epidural space
Bloody tap or convulsions due to injecting
anesthetics into vessels.
Dural puncture causing post puncture
headaches.
Maternal hypotension can cause
uteroplacental insufficiency and fetal distress

Analgesia for Vaginal Delivery

Pudendal Block
Saddle block

Pudendal block:
Used for perineal analgesia
Normally combined with a perineal and vulval
infiltration of local anaesthetic to block
ilioinguinal and genital branch of
genitofemoral nerve

Indication:
Analgesia for the second
stage of labor
Repair of an episiotomy
or perineal laceration
Outlet instrument
delivery (to assist with
pelvic floor relaxation)
Used in the past as an
alternative to neuroaxial
analgesia in assisted twin
and breech deliveries
Minor surgeries of the
lower vagina and
perineum

Contraindication:
Patient refusal
Patient's inability to
cooperate
Patient sensitivity to local
anesthetics
Presence of infection in
the ischiorectal space or
the adjacent structures,
including the vagina or
perineum
Coagulation disorders

Technique: Vaginal route

Perineal route
Vaginal route
1. A trumpet is used to guide a 15cm,17-20 gauge
spinal needle with a 20mL syringe containing 1%
lignocaine into the ischial spine
2. Vagina is pierced at ischial spine and a little
further to encroach into sacrospinous ligament
3. 10mL lignocaine is injected after making sure to
exclude a vascular entry
4. Pudendal nerve, as it winds around ischial spine
is now anaesthetised
5. Same procedure is repeated on the other side

Perineal Route
1. Going through perineum at ischial tuberosity
and guiding the needle just beyond ischial
spine, 10mL of 1% lignocaine is injected.
2. Procedure is repeated on the other side

 Along with pudendal block, perineal and vulvar infiltration is

performed to block ilioinguinal and genital branch of
genitofemoral nerve
Perineal infiltration:
For episiotomy
Perineum infiltrated with 10mL 1% xylocaine in fanwise manner
starting from middle fourchette
For outlet forceps
Needle inserted just posterior to introitus
about 10 mL of 1% xylocaine infiltrated in fanwise manner on
both side of midline
Needle then directed anteriorly along each side of vulva as far as
anterior third to block genital brach of genitofemoral and
ilioinguinal nerve.
5mL required to block each side

Saddle block:
Low spinal anaesthesia confined
to vagina and perineum
Spinal puncture is between L2-L5
with the patient in sitting position
5% solution of lignocaine is used
Patient remain in sitting position
for 5 more minutes to facilitate
drug to get fixed in lower nerve
root
Useful in midcavity forceps and
for repair of perineal or vaginal
tear after delivery

General Anaesthesia
Indications:
1.
2.

3.
4.
5.
6.
7.

Extreme emergency eg: cord prolapse,acute fetal distress,severe

haemorrhage
Maternal coagulopathy which negates a regional anaesthesia eg: HELLP
syndrome, idiopathic thrombocytopenic purpura,abruptio placenta)
Anterior placenta previa with prior caesarean anticipating an adherent
placenta,torrential haemorrhage and extensive surgery
Cardiac disease like severe MS,AS,cyanotic congenital heart disease
where regional anaesthesia will cause changes in afterload
Anatomic problems ,making regional anaesthesia difficult like severe
kyphoscoliosis,spina bifida
Internal podalic version and breech extraction
Maternal request

Technique:
1. 100% 02 is administered by tight fit mask for >3minutes
2. Induction by injection of thioentone sodium 200-250mg
(4mg/kg) as 2.5% solution IV, followed by refrigerated
suxamethonium 100mg
3. Assistant apply cricoid pressure as consciousness is lost
4. Patient is intubated with cuffed endotracheal tube and cuff is
inflated
5. Maintainance 50% N02 ,50% 02 and a trace of halothane
6. Relaxation maintained by nondepolarising muscle relaxant
7. After delivery of baby, N02 increased to 70% and narcotics
injected IV to supplement anaesthesia

Complications:
1. Mendelson syndrome
Aspiration of gastric content due to delayed
gastric emptying ( high level of serum
progesterone, decreased motilin and maternal
apprehension during labour)
Aspiration of gastric acid contents with
development of chemical pneumonitis,
atelectasis and bronchopneumonia

c/f: tachycardia, tachypnea,

bronchospasm,ronchi,cyanosis,hypotension

Px:
- Patient should not be allowed during labour
- H2 blocker(Ranitidine 150mg orally) should be
given night before and to be repeated (50mg
IM/IV) 1 hour before administration of general
anesthetic too increase gastric pH
-Metoclopramide (10mg IV) given after min 3
minutes of preoygenation to decrease gastric
volume and increase tone of lower esophageal
sphincter

Px:
- Non particulate antacid (0.3 molar sodium
citrate 30mL) given orally before transferring
patient to theatre to neutralize exusting gastric
acid
- Intubation with adequate cricoid pressure
following induction should be done
-Awake extubation should be routine

Mx:
- Immediate suctioning of oropharynx and
nasopharynxto remove inhaled matter
-Bronchoscopy is needed if there is any
particulate matter
-Continuous positive pressure ventilation to
maintain arterial 02 saturation of 95%
-Antibiotic administered when infection is
evident

Complications:
2. Bronchospasm and atelectasis(due to aspiration)
3. Blood loss due to uterine relaxation due caused
by some inhalational agents
4. Slower post op recovery
5.Failed intubation
6.Baby more acidotic

Spinal Anesthesia
Injection of local anesthetic agent into
subarachnoid space.
Used in alleviating pain of delivery and during 3rd
stage of labour.
Advantages:
i. Minimal risk of atonic PPH
ii. No neonatal depression
iii. Dangers of aspiration are less
iv. Safe

Technique
1. Informed consent is taken. Patients and
fetals vitals are continuously monitored.
2. Patient assumes a seated or lateral decubitus
position.
3. Identify the area for access (line from the top
of both iliac crests, which coincides with the
L3-L4 interspace) and clean it with antiseptic
and drape.

4. Intradermal and subQ local anesthetic

injection is given.
5. Insert the needle, directed midline or
paramedian (midline is preferred to reduce
lumbar lordorsis) until loss of resistance is
felt.
6. Remove the stylet and CSF should drip out.
7. Inject hyperbaric bupivocaine (10-12 mg) or
50-70 mg lignocaine.
8. Replace the stylet and remove the needle
and wait for 5-10 minutes for the anesthesis
to be complete and fixed.

Complications
Hypotension due to blocking of sympathetic
fibres vasodilation and low CO
Respiratory depression/paralysis due to high
spinal block
Failed block, chemical meningitis, epidural
abscess
Postspinal headache due to CSF leakage

Epidural Anesthesia
Although epidural analgesia is ideal for labour
analgesia, epidural anesthesia is not as
popular but has a definite role in C-sec of
severe preeclampsia.
Advantages: can be topped up if an epidural
was already in place and patient lands up in
an emergency C-section
Common drugs used are 2% lignocaine with
epinephrine or 3% chloroprocaine.

Combined Spinal Epidural Anesthesia

Combined advantages of rapid onset of
analgesia after spinal and able to continue
analgesia for prolonged time with epidural.
Advantages:
1. Access to top up an inadequate spinal
2. Top up to an adequate spinal if surgery gets
prolonged
3. Good post-op anesthesia through epidural
catheter.

Local Anesthesia
In rare cases of severe coagulation failure with
renal failure, other forms of anesthesia may be
harmful.
A field block of the ant. abdominal wall is done
towards the ant. edge of 8th 11th ribs B/L, with
additional infiltration over incision site.
Each layer is slowly anesthetised before incision is
made.
2% lignocaine is used.

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