UNIVERSIDAD CATOLICA DE SANTIAGO DE GUAYAQUIL

FACULTAD DE CIENCIAS MÉDICAS

CÁTEDRA DE MORFOFISIOPATOLOGIA II
COMPONENTE FARMACOLOGÍA

PRESENTACIÓN GRUPAL

TEMA:

ARTÍCULO SOBRE FARMACOLOGÍA DE LA ANALGESIA Y DE LA ANESTESIA

INTEGRANTES

ALVARADO MA. PIEDAD

AMÉN MEILIN
CALDERÓN MANUEL
CALDERÓN EMILY
CALI SUSAN
CEDEÑO KARLA

DOCENTE

DR. ROBERTO RUEDA

PARALELO

SEMESTRE A-2021
Adverse effects of neuraxial analgesia and anesthesia for obstetrics

Author: Gilbert J Grant, MD

Section Editor: David L Hepner, MD
Deputy Editor: Marianna Crowley, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jun 2021. | This topic last updated: May 27, 2021.

INTRODUCTION

Neuraxial analgesia and anesthesia (ie, spinal, epidural, combined spinal epidural, and dural puncture
epidural) for labor and delivery are generally very safe, but all interventions are associated with adverse
effects. The practice of obstetric anesthesia has evolved in large part to minimize such adverse effects.
This topic will review the side effects and complications of neuraxial anesthetic techniques used for labor
and delivery.

Serious neurologic complications of neuraxial anesthesia (eg, meningitis, spinal epidural abscess,
arachnoiditis, spinal cord injury) are discussed separately.

The relevant anatomy, techniques, indications, contraindications, and physiologic effects of neuraxial
analgesia and anesthesia are discussed in detail separately.

SIDE EFFECTS

The side effects of neuraxial analgesia and anesthesia result from the physiologic effects of neuraxial
block or direct effects of the local anesthetics and/or opioids used for the techniques.

Hypotension — Neuraxial anesthesia-induced sympathetic blockade causes vasodilation and decrease in

venous return to the heart, which can result in maternal hypotension . A reduction in blood pressure can
also occur with abrupt onset of pain relief, as may occur after intrathecal analgesic administration for
combined spinal epidural (CSE) labor analgesia. Hypotension is usually defined as either systolic blood
pressure <100 mmHg or a reduction of >20 percent from baseline.

Hypotension is considered clinically significant if it is associated with maternal symptoms such as

lightheadedness and nausea and/or deterioration of the fetal heart rate, a sign of compromised
uteroplacental perfusion.

Patients are usually positioned with left uterine displacement during cesarean delivery, and after initiation
of neuraxial labor analgesia, to avoid aortocaval compression. The need for left uterine displacement in
healthy parturients has been questioned.

● Incidence – Hypotension occurs more commonly after onset of neuraxial anesthesia for cesarean
delivery than after initiation of labor analgesia. Spinal anesthesia may result in quicker and more
profound hypotension when compared with epidural anesthesia. The reported incidence of hypotension
(systolic blood pressure <100 mmHg or <80 percent of baseline) after spinal anesthesia for cesarean
delivery is as high as 70 percent [1], and can be reduced by fluid co-loading and prophylactic
administration of vasopressors (eg, phenylephrine or ephedrine).
Hypotension occurs much less commonly after initiation of low dose neuraxial labor analgesia, with a
reported incidence between zero and approximately 14 percent.

● Fluid loading – A practical strategy for avoiding hypotension during initiation of neuraxial
anesthesia for cesarean delivery includes a rapid bolus of intravenous crystalloid (500 to 1000 mL) at the
time of induction/neuraxial placement (co-load), in conjunction with administration of vasopressors.
Intravenous fluid loading is unnecessary with the low dose epidural techniques that are usually used for
labor analgesia. In one study, there was no difference in hypotension between parturients who were
randomly assigned to receive a one liter IV crystalloid bolus or no preload before initiation of epidural
labor analgesia (ELA; 6 and 10 percent, respectively)

● Vasopressors – For prevention of neuraxial anesthesia-induced hypotension during cesarean

delivery, for most patients we suggest prophylactic, titrated administration of low-dose phenylephrine
infusion (ie, starting at 50 mcg/min) with phenylephrine rescue boluses, along with crystalloid co-loading,
aiming for maternal blood pressure close to baseline. Phenylephrine is the preferred vasopressor rather
than ephedrine for most patients in this setting in the absence of bradycardia. Limited data suggest that
norepinephrine may be beneficial for prevention and treatment of spinal hypotension during cesarean
delivery.

Symptomatic hypotension during labor is usually easily treated with small IV doses of phenylephrine (eg,
40 to 80 mcg) or ephedrine (eg, 5 to 10 mg) and IV fluids. Repeated doses of phenylephrine and/or
ephedrine should be administered as needed until the hypotension is corrected. An infusion of
phenylephrine is rarely required during low-dose neuraxial labor analgesia.

Prophylactic administration of ephedrine or phenylephrine prior to labor analgesia is not indicated when
low-dose techniques are used.

Pruritus — Pruritus is a common side effect of neuraxial opioid administration, and is more likely to
occur in pregnant and postpartum women than in other patient populations. Fentanyl and sufentanil are
relatively lipid soluble and may cause pruritus in the legs, abdomen, and thorax. Morphine and
hydromorphone, which are much more water-soluble, may cause pruritus in the neck and head as well.
● Pruritus occurs more commonly after intrathecal opioid administration than after epidural
administration, with a reported incidence of close to 100 percent for fentanyl, which is often used for CSE
labor analgesia. In a meta-analysis of 11 trials involving 959 women, CSE was associated with more
pruritus than low-dose epidural (average risk ratio [RR] 1.80; 95% CI 1.22-2.65).
● The incidence of pruritus after neuraxial opioid administration is dose dependent.
● The duration of pruritus after intrathecal or epidural administration of the lipid soluble opioids
fentanyl and sufentanil is relatively brief compared to the duration of pruritus associated with neuraxial
morphine and hydromorphone.
● Co-administration of local anesthetics (LAs) with opioids may reduce the incidence of pruritus.

The etiology of neuraxial opioid-induced pruritus is unclear, but it is not caused by histamine release.
Thus, treatment with an antihistamine such as diphenhydramine is not indicated, as any benefit is
probably due to sedation or placebo effect.

The most effective treatment for opioid-induced pruritus is administration of a small dose of an opioid
antagonist such as naloxone (40 to 80 mcg intravenously [IV], or infusion at 0.25 to 1 mcg/kg/h IV),
naltrexone (6 mg orally), or the mixed opioid agonist-antagonist nalbuphine (2.5 to 5 mg IV). Higher
doses or infusion of any opioid antagonist may reverse analgesia. Limited literature suggests that
nalbuphine may be more effective for relief of pruritus than naloxone, but is associated with increased
sedation. Practice for treatment of neuraxial opioid induced pruritus varies: one contributor on this topic
administers nalbuphine 2.5 to 5 mg IV in this setting, whereas the other administers naloxone 40 to 80
mcg IV, repeated in five minutes if necessary, and patient controlled intravenous naloxone when indicated
for prolonged pruritus.

Other drugs that have been studied for the prevention and/or treatment of opioid induced pruritus include
intravenous propofol, serotonin antagonists, and glucocorticoids. A systematic review of randomized
trials of treatment and/or prevention of pruritus found that intravenous naloxone, naltrexone, nalbuphine,
and droperidol were effective in the prevention of opioid induced pruritus, based on overall low quality
data.

Studies of the effect of serotonin (5-HT3) receptor antagonists on opioid induced pruritus have reported
conflicting results. A meta analysis of nine randomized trials involving patients who received intrathecal
morphine for cesarean delivery reported that the incidence of pruritus was not reduced by prophylaxis
with 5-HT3 receptor antagonists compared with placebo (81 percent versus 86 percent). However, 5-HT3
receptor antagonists reduced the severity and need for treatment of pruritus, were effective for treatment
of established pruritus, and reduced the incidence of postoperative nausea and vomiting and the need for
rescue antiemetic therapy. Practice varies regarding administration of 5-HT3 receptor antagonists; one
contributor on this topic routinely administers ondansetron after cord clamping because of its benefits and
low incidence of side effects, and the other does not.
Nausea and vomiting — Nausea and vomiting occur commonly in the peripartum period, with or
without neuraxial analgesia. Nausea may result from labor itself, as a side effect of systemic opioid
administration, or for one of several anesthesia related causes, including the following:

● Hypotension – Nausea and vomiting may be caused by hypotension during neuraxial labor
analgesia, or more commonly during neuraxial anesthesia for cesarean delivery. Nausea usually resolves
with correction of blood pressure, and rarely requires further treatment.
● Neuraxial opioids – Nausea is an uncommon side effect of neuraxial administration of the
lipophilic opioids (eg, fentanyl or sufentanil), which are often administered for labor analgesia, with a
reported incidence <2.5 percent. Nausea may be more likely after CSE than after ELA.

Nausea and vomiting are more common after administration of neuraxial morphine, which is usually
administered for post cesarean delivery pain. In a meta-analysis of studies of the effect of serotonin
receptor antagonists for prevention of side effects of 0.1 to 0.2 mg intrathecal morphine, the reported
incidence without prophylaxis of postoperative nausea was 30 to 37 percent, and the incidence of
postoperative vomiting was 10 to 35 percent. Prophylactic administration of ondansetron reduced the
incidence and severity of nausea and vomiting, and the need for postoperative rescue antiemetic. Other
drugs that are reported to reduce neuraxial opioid induced nausea and vomiting in various patient
populations include metoclopramide, dexamethasone, and transdermal scopolamine. An infusion of low
dose naloxone was used in one reported case of intractable nausea and vomiting associated with
intrathecal morphine.

Neuraxial hydromorphone may be administered for postcesarean delivery pain when morphine is
unavailable. Most studies have reported an incidence of nausea and vomiting with hydromorphone similar
to neuraxial morphine.

Urinary retention — Urinary retention is a possible side effect of both neuraxial analgesia and
anesthesia. Both neuraxial local anesthetics and neuraxial opioids can cause decreased ability to sense a
full bladder and to void. Small observational and randomized trials have reported an association between
ELA and intrapartum or postpartum urinary retention, though a cause
and effect relationship has not been proven, and postpartum bladder dysfunction is common in patients
who have no anesthesia.

Urinary retention may be less common with the low concentration epidural solutions that are commonly
used, compared with the higher concentration solutions that were used in the past. In one trial, more
patients randomly assigned to low dose labor analgesia (0.1% bupivacaine with fentanyl) were able to
void spontaneously than those who received more concentrated epidural solutions (0.25% bupivacaine)
(32 percent versus 11 percent).

Bladder distention should be considered if patients complain of breakthrough pain during labor analgesia,
and bladder catheterization should be performed as necessary.

Fever — Randomized trials and observational studies have consistently reported an association between
the use of epidural analgesia and rise in maternal temperature. The etiology of the temperature increase
associated with epidural analgesia is incompletely understood. This is discussed separately.

Shivering — Postpartum shivering is a common event, even in the absence of analgesia/anesthesia for
labor and childbirth.
Shivering related to neuraxial anesthesia is not fully understood, but may be caused in part by
sympathetic block-induced vasodilation, with redistribution of body heat from the core to the periphery.
Shivering can be bothersome and can interfere with blood pressure monitoring. Patients may be warmed
with heated blankets or forced air warming systems. Further treatment with intravenous meperidine (12.5
to 25 mg IV) may be used when necessary.

COMPLICATIONS

Local anesthetic systemic toxicity — Local anesthetic systemic toxicity (LAST) in obstetric anesthesia
most commonly occurs after inadvertent injection of high volume of a high concentration of local
anesthetic into an epidural vein. Pregnant patients, especially at term, are at increased risk for LAST
because of the physiologic and hormonal changes of pregnancy.
LAST is uncommon during labor analgesia because of the low concentration of local anesthetics used for
epidural labor analgesia (ELA).

LAST primarily affects the central nervous system and cardiovascular system, and may be fatal. The
clinical presentation, prevention, and management of LAST are discussed separately.

Inadequate anesthesia — Failed neuraxial block may be defined as inadequate analgesia/anesthesia

following an epidural, spinal, or combined spinal–epidural (CSE) technique. The reported incidence of
failed block varies, and may be affected by patient factors (eg, obesity, anatomic or postsurgical spine
abnormalities), stage of labor, skill of the anesthesia clinician, the specific neuraxial technique, and/or
technical factors (eg, equipment used, depth of catheter insertion).

In one single institution review of anesthesia records and quality assurance data for approximately 12,500
neuraxial labor analgesia techniques, the overall failure rate was 12 percent, with a lower failure rate for
CSE compared with epidural analgesia (10 versus 14 percent). In the same review, seven percent of labor
epidurals failed when used for cesarean delivery, and spinal anesthesia planned for cesarean delivery
failed in 2.7 percent of patients. In another single institution prospective study of 250 parturients who
received epidural analgesia, inadequate analgesia at 30 minutes after block initiation occurred in 17
percent of patients.

Management of inadequate analgesia during labor, and management of failed neuraxial anesthesia for
cesarean delivery are discussed separately.

Motor block — Neuraxial administration of local anesthetics in high concentrations causes motor block,
an undesirable side effect during labor. The drugs and administration techniques (eg, patient controlled
epidural analgesia, programmed intermittent epidural bolus) for neuraxial analgesia are chosen in part to
minimize motor block.
The drugs used for neuraxial labor analgesia techniques usually include a combination of dilute local
anesthetic and a lipid soluble opioid. The combination allows the use of lower doses of each agent,
thereby minimizing side effects, including motor block. Maintenance of motor function preserves the
parturient's ability to push, may allow her to ambulate (if only to the bathroom), maintains maternal
satisfaction, and may reduce the effects of neuraxial anesthesia on the incidence of instrumental delivery.

High neuraxial block — Total spinal anesthesia can be a complication of either spinal or epidural
anesthesia. It may result from the unrecognized and unintentional injection of medication intended for the
epidural space into the subarachnoid or subdural space (via a malpositioned catheter or needle), transfer
of medication from the epidural space into the subarachnoid space through a dural rent, or an overdose of
medication injected into the subarachnoid space. The reported incidence in the obstetric population in the
United States is 1 in 4336 blocks. A study of data from 2011 to 2014 from the United Kingdom Obstetric
Surveillance System reported 66 cardiac arrests during approximately 2,350,000 pregnancies. The leading
cause of cardiac arrest was a complication of obstetric anesthesia (nearly one in four pregnant patients
who had cardiac arrest); 10 of the 17 arrests attributed to obstetric anesthesia resulted from total spinal
anesthetic following de novo intrathecal block.

High or total spinal block is discussed separately.

Post dural puncture headache — Post dural puncture headache (PDPH; also called spinal headache or
post lumbar puncture headache) is a positional headache (ie, worse when the patient sits or stands) that
occurs because of leakage of cerebrospinal fluid (CSF) through a dural puncture. PDPH may occur after
spinal anesthesia (ie, intentional dural puncture) or after unintentional dural puncture (UDP) with an
epidural needle. The mechanism of headache after CSF leak is unclear, but appears to involve cerebral
vasodilation and/or traction on intracranial structures.

● Incidence – The rate of PDPH after dural puncture varies widely across patient populations;
young pregnant women with a low body mass index (BMI) are at highest risk. A meta-analysis of 51
randomized and observational studies of PDPH in over 300,000 obstetric patients reported a risk of UDP
of 1.5 percent, with a risk of PDPH of approximately 52 percent after UDP.

The risk of PDPH after dural puncture with a spinal needle was 1.5 to 11.2 percent, and varied with the
size and type of spinal needle. Treatment – Most PDPHs will resolve in 7 to 10 days if untreated.
Conservative management with symptomatic therapy (eg, oral analgesics, caffeine) may be indicated if
the patient does not desire epidural blood patch (EBP) or if the headache is not severe .

● Epidural blood patch – The classic treatment for severe, debilitating PDPH is EBP. The initial
blood patch gives complete or partial relief in 95 percent of obstetric patients with PDPH, but the
headache may recur. In one series, headache recurred in 31 percent of parturients who had an EBP for
PDPH, and 28 percent received more than one EBP. EBP is performed by injecting the patient's blood into
the epidural space to form a clot over the dural defect. EBP is thought to work by two mechanisms,
initially by increasing the subarachnoid CSF pressure, and later by forming a fibrin plug that seals the
hole in the dura and prevents further CSF leak. EBP is discussed in detail separately.
● Sphenopalatine ganglion block – A novel noninvasive approach to treating PDPH using an old
technique, transnasal sphenopalatine ganglion block (SPGB), has been described in case reports and case
series. Although there are no prospective trials comparing this treatment with other treatments of PDPH,
because it is low-risk, the author offers SPGB to all patients with PDPH. He suggests it particularly for
patients who do not desire a blood patch, or for whom a blood patch is relatively or absolutely
contraindicated. Transnasal sphenopalatine block for PDPH is discussed separately.

Other therapies to treat or prevent PDPHs have not been consistently efficacious.

● Prophylactic epidural blood patch – An EBP may be performed prophylactically, before a

headache occurs after an inadvertent dural puncture. Blood is injected into the epidural catheter prior to
its removal after delivery. The efficacy of prophylactic EBP is unclear.
● Spinal catheter – Threading an epidural catheter into the intrathecal space at the time of UDP has
been advocated to reduce the incidence of PDPH. We do not routinely place an intrathecal catheter after
UDP, but place intrathecal catheters selectively (eg, after a difficult epidural procedure). The efficacy of
intrathecal catheter placement has not been established in randomized controlled trials, and most studies
have reported no benefit of intrathecal catheter placement.

Pneumocephalus — Injection of air into the subarachnoid space during placement of neuraxial block
may result in acute onset of severe headache and other neurologic signs and symptoms. This complication
may occur with an unintentional dural puncture if air, rather than saline, is used for loss of resistance to
identify the epidural space.

A pneumocephalus headache can occur within a few seconds if the epidural is placed with the patient in
the sitting position, but may be delayed until she sits up if the epidural is placed in the lateral decubitus
position. Treatment of pneumocephalus headache is symptomatic. An EBP is of no value for this type of
headache.

Spinal epidural hematoma — Hemorrhage into the neuraxis, a rare complication of spinal and epidural
techniques, may occur if a blood vessel is punctured by a needle and/or catheter. Spinal epidural
hematoma (SEH) can occur in any patient and may occur spontaneously without neuraxial
instrumentation, but is more likely in patients with disorders of coagulation and in those receiving
anticoagulants. The incidence of SEH appears to be significantly lower in obstetric patients than in other
populations. Retrospective studies have reported an incidence of spinal hematoma in obstetric patients
between 0 and 0.6 per 100,000 epidural catheterizations. As an example, an analysis of data from the
Nationwide Inpatient Sample found 15 epidural hematomas among over 2,300,000 obstetric epidural
catheterizations, for an incidence of 0.6 per 100,000.

SEH is less likely with a single-shot spinal technique due to the relatively small size of the spinal needle
and the lack of an indwelling catheter.

The diagnosis of spinal epidural hematoma is complicated by the concealed nature of the bleeding; thus, a
high index of suspicion must be maintained. The most common presenting symptoms of neurologically
significant SEH are progressive motor and sensory block, and bowel or bladder dysfunction.

Back pain occurs in only 25 percent of cases. Low-dose techniques for labor analgesia produce minimal
motor block and facilitate continuous monitoring of lower extremity function in patients at risk for
development of neuraxial hematoma. Evaluation and management of suspected SEH are discussed
separately.

Neuraxial analgesia and the anticoagulated patient — Pregnant women may be treated with
anticoagulants for a variety of indications, including thrombophilia or history of venous thrombosis or
thromboembolism. The risk of hemorrhage into the neuraxis is increased in anticoagulated patients; thus,
one must consider the type of anticoagulant used, the dose, and the timing of its administration.

Neuraxial analgesia and low platelets — A low platelet count or deficient platelet function predispose
to SEH upon neuraxial instrumentation. The precise platelet count needed to safely perform neuraxial
analgesia is unknown, because epidural hematoma is so rare in parturients. Estimates of risk are based on
reported neuraxial techniques in parturients with thrombocytopenia. As an example, a review of 1525
reported neuraxial techniques performed in parturients with thrombocytopenia found no cases of epidural
hematoma, as indicated by the need for decompressive laminectomy.

The upper bounds of the 95 percent confidence intervals for the incidence of epidural hematoma were 11
percent for a platelet count <49,000/microL, 3 percent for a platelet count of 50,000 to 69,000/microL,
and 0.2 percent for a platelet count 70,000 to 100,000/microL, based solely on the number of patients in
each group. Similarly, in a subsequent single center review of 308 parturients who had neuraxial block
with a platelet count <100,000/microL, there were no SEHs. It is difficult to draw a conclusion for those
parturients with platelet count below 70,000/microL, because neuraxial block was avoided in the majority
of these parturients. When the authors analyzed this data along with the data from the study above, the
upper bounds of the 95% confidence interval for the incidence of epidural hematoma with a platelet count
70,000 to 100,000 was 0.19 percent.

The threshold platelet count for performing neuraxial techniques varies among clinicians, and should be
individualized based on patient factors, including the specific patient's risks associated with general
anesthesia should it become necessary. Our approach is consistent with a 2021 consensus statement from
the Society for Obstetric Anesthesia and Perinatology (SOAP), which is shown in an algorithm. We
typically avoid neuraxial anesthesia in thrombocytopenic patients with a history of bleeding associated
with thrombocytopenia or current signs of coagulopathy (eg, bleeding from intravenous catheter sites or
mucous membranes). We perform neuraxial anesthesia techniques in patients without a bleeding history
with stable platelet counts above 70,000/microL. For patients with platelet counts 50,000 to
70,000/microL, we perform neuraxial anesthesia if there is compelling reason to do so after risk-benefit
analysis, and prefer a spinal rather than an epidural technique. We avoid neuraxial techniques in patients
with platelet counts below 50,000/microL.

The rate of decline of the platelet count should be considered when deciding when or whether to perform
neuraxial techniques. The platelet count may decline precipitously in patients with HELLP syndrome. In
these patients, the platelet count should be measured within six hours of performing a neuraxial block or
removing a neuraxial catheter, and compared with previous counts.

It is not necessary to routinely obtain a platelet count before administration of regional anesthesia in
parturients with no history or clinical evidence of a coagulation disorder (bleeding, bruising).
Respiratory depression — Respiratory depression is a risk when opioids are administered by any route,
including neuraxial injection. Clinically significant respiratory depression after neuraxial opioids is rare at
usual doses; risk is increased by prior or concomitant administration of systemic opioids.

The time course of neuraxial opioid induced respiratory depression depends on the lipid solubility of the
drug.

● After neuraxial bolus administration of a lipophilic opioid (eg, fentanyl or sufentanil) respiratory
depression, if it occurs, would be expected within approximately two hours.
● Respiratory depression after neuraxial administration of hydrophilic opioid (eg, morphine,
hydromorphone) is delayed, and may not occur until 12 hours or more after injection, when a patient is
usually on a postpartum floor without intensive monitoring. Thus, a protocol should be in place for
postpartum care including respiratory monitoring for all patients who receive neuraxial opioids for
postoperative pain control.

Respiratory depression after neuraxial hydrophilic opioids is much less common in parturients than in
other patient populations. SOAP published a consensus statement on monitoring following administration
of neuraxial morphine for cesarean delivery analgesia, stratified based on the dose of neuraxial opioid and
patient risk factors. These issues are discussed in detail separately.

Neuraxial opioid induced respiratory depression is treated with intravenous administration of an opioid
antagonist (eg, naloxone). The dose should be titrated to effect (40 to 80 mcg IV increments), followed by
an infusion at a dose sufficient to maintain an adequate respiratory rate until the effect of the opioid has
dissipated (eg, 1 to 2 mcg/kg/minute).

Backache — Localized back pain related to tissue trauma at the site of a neuraxial procedure may be
present for several days, but prospective studies have consistently reported no correlation between
neuraxial analgesia and long term back ache.

Postpartum neuropathy — Neurologic complications associated with neuraxial anesthesia are extremely
rare. Neurologic injury can be the result of needle or catheter trauma, drug toxicity, spinal epidural
hematoma, or infection, and may involve injury to the spinal cord, nerve roots, or neuraxial vasculature.
The incidence of most neurologic complications has not been determined because they are so rare.
Neurologic complications of obstetric anesthesia are discussed in detail separately.

Postpartum neuropathies usually have obstetric etiologies, and are often due to compression of nerves of
the lumbosacral plexus by the descending fetal head, extrinsic neural compression (eg, by stirrup
supports) or from ischemia due to prolonged stretching of nerves (eg, extreme hip flexion) during the
second stage of labor.

Severe infection — Epidural abscess and meningitis are uncommon but potentially catastrophic
complications of neuraxial anesthesia procedures. Epidural abscess is more likely to occur after epidural
techniques, particularly after prolonged epidural catheterization, whereas meningitis typically occurs after
the dura has been punctured, either intentionally as part of a spinal anesthetic or unintentionally as a
complication of an epidural procedure. Spinal epidural abscess is discussed separately.
FETAL EFFECTS

Neuraxial analgesia can affect the fetus directly by placental transfer of local anesthetic or opioids, or
indirectly via maternal effects (ie, hypotension or uterine hypertonus).

Placental perfusion — The placental bed is not autoregulated and, therefore, its perfusion is entirely
dependent upon maternal blood pressure. Hypotension caused by neuraxial block can result in decreased
fetal oxygenation and a deterioration in the fetal heart rate pattern (eg, bradycardia, repetitive late
decelerations).

However, in the absence of hypotension, epidural local anesthetics have been shown to improve
intervillous blood flow, to have minimal effect on uterine or fetal umbilical vasculature as assessed by
Doppler velocimetry, and to be associated with improved neonatal acid–base status.

Fetal bradycardia — Initiation of neuraxial analgesia may be followed by fetal heart rate abnormalities
(eg, bradycardia, reduced variability, late decelerations) as a result of hypotension, uterine hyperactivity,
or increased uterine tone. In the absence of hypotension, transient fetal heart rate abnormalities in this
setting presumably relate to a reduction in maternal circulating epinephrine after rapid onset of analgesia,
and loss of epinephrine's beta-sympathomimetic relaxant effects on the myometrium. The resulting
uterine hypertonus can compromise placental blood flow. Fetal bradycardia after rapid onset of analgesia
usually occurs within the first 15 minutes, and when treated with usual measures, does not result in fetal
acidemia, low Apgar scores, or the need for cesarean delivery.

If fetal bradycardia occurs after initiation of neuraxial analgesia, treatment should include the following:

● Discontinue intravenous oxytocin

● Place the parturient in the lateral decubitus position to relieve aortocaval compression
● Administer supplemental oxygen
● Correct hypotension
● Fetal scalp stimulation
● For persistent uterine hypertonus or tachysystole, administer tocolytic medication (eg,
nitroglycerin 60 to 90 mcg intravenously repeated in two to three minutes, if necessary, followed by
terbutaline 250 mcg subcutaneously if there is no response to nitroglycerin)

Most studies have reported that fetal bradycardia is more common after intrathecal opioid administration,
usually as part of combined spinal-epidural analgesia, than after initiation of epidural analgesia. A 2020
meta-analysis of randomized trials reported an increased risk of fetal bradycardia for combined
spinal-epidural (CSE) compared with standard epidural labor analgesia (ELA) technique (RR 2.38, CI
1.57-3.62). Rates of cesarean delivery and apgar scores at 1 and 5 minutes were similar.

EFFECTS ON THE PROGRESS AND OUTCOME OF LABOR

Obstetric anesthesia practice has evolved with the goal of reducing or eliminating deleterious effects on
the progress or outcome of labor and delivery.

● Timing of neuraxial analgesia – The timing of administration of neuraxial analgesia (early

versus later in labor) has been shown to have no effect on the rate of cesarean delivery or other obstetric
outcomes. A 2014 meta-analysis of nine studies including over 15,000 patients that compared early
initiation (<4 cm cervical dilatation) with later initiation of neuraxial analgesia reported no difference in
cesarean delivery rate, instrumental delivery, duration of second stage of labor, or fetal outcomes. Thus,
epidural analgesia should be administered on request for patients who are clearly in labor, without waiting
for a specific degree of cervical dilation .
● Cesarean delivery – Multiple randomized trials have shown that neuraxial analgesia does not
increase the risk of cesarean delivery. A 2018 meta-analysis of 40 randomized trials that compared
neuraxial analgesia with non-neuraxial analgesia or no analgesia reported that epidural analgesia did not
significantly increase the risk of cesarean delivery (relative risk 1.07, 95% CI 0.96-1.08).
● Instrumental delivery – Neuraxial analgesia using high concentrations of local anesthetic (LA)
may increase the risk of instrumental delivery. However, standard obstetric anesthesia practice now
involves the use of low concentration LA/opioid solutions for labor analgesia, partly to minimize the
degree of motor block, and to preserve the ability to push during the second stage of labor.
A 2013 meta-analysis of randomized controlled trials that compared low concentration epidural LA for
labor (eg, ≤0.1% bupivacaine or ≤0.17% ropivacaine) with higher concentration solutions found a
reduced risk of instrumental delivery with the use of low concentration LAs (odds ratio [OR] = 0.70; 95%
CI 0.56 to 0.86). Similarly, a 2017 meta-analysis of studies using only dilute epidural LA found no
difference in the instrumental delivery rate between patients who had epidural analgesia, and those who
did not. A 2018 meta-analysis of randomized trials that compared epidural with non-epidural analgesia or
no analgesia for labor reported no difference in instrumental delivery rate in trials conducted after 2005.

● Duration of labor – Neuraxial analgesia may decrease the duration of the first stage of labor, and
may prolong the second stage of labor to a variable degree.
● First stage of labor – A number of prospective randomized trials that compared epidural or
intrathecal analgesia with systemic opioid analgesia for labor have reported shorter labor after early
administration of neuraxial analgesia. As an example, in one trial, 750 nulliparous women were randomly
assigned to receive intrathecal fentanyl or systemic hydromorphone at first request for analgesia. The
median time from initiation of analgesia to full cervical dilation was significantly shorter after neuraxial
analgesia (295 minutes versus 385 minutes).
● Second stage of labor – The effect of neuraxial analgesia on the second stage of labor, and the
clinical relevance of reported effects, are unclear, partly because the start of second stage (complete
cervical dilation) is difficult to measure and depends on the timing of a cervical examination, rather than a
defined obstetrical event. Retrospective reviews have reported an association between epidural analgesia
and a longer second stage of labor. A multicenter retrospective study including approximately 62,400
nulliparous patients who delivered between 2002 and 2008 reported that the 95 percentile in the duration
of the second stage of labor was approximately 50 minutes longer in patients who had epidural analgesia
than those who did not (3.6 versus 2.8 hours). In another retrospective review of labor in 22,370
nulliparous women between 1976 th and 2008, epidural analgesia use prolonged 95 percentile duration of
the second stage of labor by 2 hours and 19 minutes (197 minutes without epidural versus 336 minutes
with epidural).
Randomized trials have reported a much smaller effect of epidural analgesia on the duration of the second
stage of labor. In addition, the use of low concentration epidural LA solutions (which is the current
standard of care) may minimize prolongation of the second stage of labor, compared with higher
concentrations. A 2011 meta-analysis of studies of neuraxial labor analgesia (with mixed low and higher
concentration LAs) reported a mean increase of 13.66 minutes in the second stage of labor with the use of
neuraxial analgesia, whereas a 2017 meta-analysis (exclusively low concentration LAs) reported a
statistically insignificant mean increase of 5.7 minutes. Similarly, meta-analysis of studies that compared
higher concentration epidural LA with dilute LA solutions found a shorter second stage of labor
(weighted mean difference -14 minutes) with the use of dilute solutions.

EFFECTS ON BREASTFEEDING

The effects of neuraxial analgesia on breastfeeding are controversial and difficult to study, and existing
literature is insufficient to make recommendations on this issue. Studies of the effects of labor analgesia
on breastfeeding have reported conflicting results, and have included heterogeneous patient populations
and labor analgesia techniques, and differing methods for evaluating breastfeeding.

Multiple patient factors affect the likelihood that a patient will breast feed in the postpartum period and
long term. Compared with systemic opioids for labor analgesia, neuraxial techniques result in lower or
negligible fetal opioid levels, and would therefore be expected to interfere less with neonatal feeding
behaviors.

A randomized trial including approximately 950 parturients reported no difference in the breastfeeding
rate at six weeks or three months among those who received labor analgesia with epidural bupivacaine
with or without fentanyl 1 mcg/mL or 2 mcg/mL.

The patients in this trial were multiparous, had previously breastfed an infant, and planned to breastfeed
for more than three months; results may not apply to other patient populations.

EFFECTS ON THE NEONATE

In the absence of maternal hypotension prior to delivery, neuraxial analgesia and anesthesia do not
negatively affect the neonate.

Opioids administered systemically or epidurally rapidly enter the maternal circulation, cross the placenta,
and equilibrate with fetal circulation. However, with the low concentrations of lipophilic opioids (eg,
fentanyl and sufentanil) used for labor analgesia, even prolonged epidural opioid infusion rarely causes
fetal accumulation, neonatal respiratory depression, or reduced neonatal behavioral scores. Similarly, with
the dilute concentrations of local anesthetics used for labor, minimal placental drug transfer and neonatal
accumulation occur. Neurobehavioral studies in neonates whose mothers received epidural analgesia or
systemic opioids have shown either no difference or improved scores in neonates of mothers receiving
epidurals. A meta-analysis of 10 randomized trials reported that neonates of mothers who received
epidural analgesia had fewer Apgar scores below seven and required naloxone less often than those
whose mothers received systemic opioids.

Epidural fentanyl is routinely administered as an adjunct to local anesthetics during epidural anesthesia
for cesarean delivery, to improve intraoperative analgesia. Many clinicians wait until the umbilical cord is
clamped to administer fentanyl, to avoid any risk of fetal transfer. However, many studies have reported
no effects on neonatal outcomes (eg, Apgar scores, umbilical blood gases, neonatal behavioral tests) with
administration of 50 to 100 mcg of epidural fentanyl during initiation of epidural anesthesia, prior to cord
clamp. Epidural morphine is routinely administered for postoperative pain relief, after the umbilical cord
is clamped, and therefore has no effect on the neonate.

The doses of opioid used for intrathecal administration are considerably lower than epidural doses, and
maternal systemic uptake is negligible, such that direct fetal or neonatal effects are unlikely to occur.

EPIDURAL ANALGESIA AND CHILDHOOD AUTISM

After review of available data, we believe that there is no convincing evidence that labor epidurals cause
autism spectrum disorder (ASD) or other types of behavioral or learning disabilities in the parturient's
infant, and no evidence that choosing another form of pain relief for labor, or no pain relief, reduces the
risk of autism or other disabilities.

Relevant evidence consists of retrospective observational or database studies, and results are mixed. In
studies that have shown an association between epidural analgesia and offspring risk of ASD, that
association usually disappears when adjusting for confounders. Examples of such studies are as follows:

● In a retrospective case control study of 465 children with ASD, 481 siblings of those children, and
1313 controls, the rate of epidural use during labor was higher in mothers who delivered children who
were later diagnosed with ASD. However, the rate of obstetric complications was also higher in mothers
of children with ASD, and the reasons for epidural placement (eg, obstetric complications, pain relief)
were not available, raising the possibility that the association between epidural use and ASD was due to
complications for which the epidural was placed. The rate of epidural use during delivery of siblings
without ASD was similar to the rate of epidural use in for delivery of children with ASD, supporting a
lack of a causative relationship between epidurals and ASD.
● A large retrospective longitudinal birth cohort database study published in 2020 reported an
association between labor epidural analgesia (LEA) in parturients and the diagnosis of autism in their
children. Among approximately 148,000 women who delivered vaginally, ASD was diagnosed in 1.9
percent of children of mothers who received LEA, compared with 1.3 percent of children in the non-LEA
group (adjusted hazard ratio 1.37, 95% CI 1.23-1.53). However, like all observational studies, a causal
relationship between LEA and autism was not established. There were significant methodologic problems
with this study; there were numerous demographic differences between the cohort of patients who
received LEA and those who did not, including factors that have been associated with an increased risk of
autism. In addition, potentially important details about the course of labor and delivery and other possible
causes of autism were not provided. Since the etiology of autism is unknown, even after controlling for
known risk factors, there remains the possibility that the association between LEA and autism was due to
unknown confounders.

In response to publication of this study, five major obstetric and anesthesia societies (Society for Obstetric
Anesthesia and Perinatology, American Society of Anesthesiologists, Society for Pediatric Anesthesia,
American College of Obstetrics and Gynecology, and the Society for Maternal-Fetal Medicine) issued a
joint statement that this study does not provide credible evidence that LEA causes autism. Other
anesthesia and obstetric professional societies in Canada and the United Kingdom have also issued
statements on the methodologic problems of the study and lack of evidence that labor epidurals cause
autism.

● A large population-based cohort study of over 123,000 vaginal singleton births in Manitoba,
Canada from 2005 to 2016 used information from four statewide databases to evaluate the association
between exposure to maternal epidural labor analgesia (ELA) and autism diagnosed after the age of 18
months in offspring. After adjusting for maternal sociodemographic, pregnancy-related and preexisting
factors, and birth-specific factors, there was no association between ELA exposure and increased risk of
autism in offspring (adjusted hazard ratio 1.08 (95% CI 0.78-1.22).

ALLERGIC REACTION TO LOCAL ANESTHETIC

Allergic reactions to local anesthetics (LAs) are very rare. Most allergic reactions are delayed-type, cell
mediated reactions (delayed local swelling or contact dermatitis), which are rarely dangerous. They occur
more commonly with ester LAs (eg, 2-choloroprocaine, tetracaine) than with amide LAs (eg, lidocaine,
bupivacaine, ropivacaine). Serious IgE-mediated reactions can also occur, including life threatening
anaphylaxis. Patients who describe symptoms suggestive of this type of reaction should be referred to an
allergist if possible. Skin testing and graded challenge can determine which specific drugs the patient can
safely receive. Allergic reactions to LAs are discussed separately.

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions around the
world are provided separately.

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The
Basics patient education pieces th th
are written in plain language, at the 5 to 6 grade reading level, and they answer the four or five key
questions a patient might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. th
Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These
articles are written at the 10 to th
12 grade reading level and are best for patients who want in-depth information and are comfortable with
some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on "patient info" and the keyword(s) of interest.)

●
Basics topics

SUMMARY AND RECOMMENDATIONS

Neuraxial analgesic and anesthetic techniques for labor and delivery are associated with side effects and
complications. Some are ●
more common than others.

●
Side effects

○ Hypotension may occur primarily as a result of the sympathetic blockade associated with
neuraxial block, and is more common during anesthesia for cesarean delivery than during labor analgesia.
For prevention of neuraxial anesthesia-induced hypotension during cesarean delivery, for most patients
we suggest prophylactic administration of a vasopressor along with intravenous crystalloid coloading
(Grade 2C). We administer a low-dose phenylephrine infusion (ie, starting at 50 mcg/min) with
phenylephrine rescue boluses, along with a rapid bolus of intravenous crystalloid (500 to 1000 mL), at the
time of induction or neuraxial anesthesia placement, aiming for maternal blood pressure close to baseline.
The patient is typically positioned with left uterine displacement to prevent aortocaval compression.
○ Pruritus is a common side effect of neuraxial opioids, and is treated most effectively with
administration of a small dose of opioid antagonist (eg, naloxone [40 to 80 mcg intravenously]),
naltrexone (6 mg orally), or the mixed opioid agonist-antagonist nalbuphine (2.5 to 5 mg intravenously
[IV]).
○ Intrapartum fever, nausea and vomiting, urinary retention, and shivering are other possible side
effects of neuraxial analgesia or anesthesia.

●
Complications

○ Pregnant patients are at higher risk of post dural puncture headache (PDPH) than other patients.
Severe PDPH is usually treated with an epidural blood patch (EBP).
○ Local anesthetic systemic toxicity (LAST) is a rare but potentially lethal complication of epidural
administration of local anesthetics. Pregnant patients are at increased risk for LAST when high doses of a
high concentration local anesthetic are administered.
○ Inadequate analgesia, motor block, and high neuraxial block are complications that can be
minimized by management techniques and choice of neuraxial drugs.
○ Spinal epidural hematoma is a rare, potentially devastating complication of neuraxial anesthesia
techniques, that is more common in patients who are coagulopathic, either because of anticoagulant
medication, systemic disease, or thrombocytopenia. For patients with thrombocytopenia, we perform
neuraxial anesthesia in patients without a bleeding history with stable platelet counts above
70,000/microL. For patients with platelet counts 50,000 to 70,000/microL, we perform neuraxial
anesthesia if there is compelling reason to do so after risk-benefit analysis, and prefer a spinal rather than
an epidural technique.
○ Postpartum neuropathies usually have obstetric causes. Very rarely, neurologic complications can
be the result of needle or catheter trauma, drug toxicity, spinal epidural hematoma, or infection, related to
neuraxial anesthesia techniques.
○ Strict aseptic technique should be followed during neuraxial anesthesia techniques, to reduce the
risk of meningitis and epidural abscess, which are rare, serious complications.
● Fetal effects
● Neuraxial analgesia can affect the fetus directly by placental transfer of local anesthetic or opioids,
or indirectly via maternal effects (ie, hypotension or uterine hypertonus). Placental transfer of drugs is
rare with low-dose epidural or spinal drug administration.
● In the absence of hypotension, fetal bradycardia may occur with abrupt onset of analgesia, and is
more common after intrathecal opioid administration for labor analgesia than after initiation of epidural
analgesia. Fetal bradycardia in this setting is typically transient, and when treated with usual measures,
does not increase the risk of cesarean delivery or adverse neonatal outcomes.

Effects on the progress and outcome of labor — Low dose neuraxial labor analgesia techniques
administered at any time during labor do not increase the risk of cesarean delivery or instrumental
delivery. Neuraxial analgesia may shorten the first stage of labor, and may prolong the second stage of
labor to a variable degree.

Breastfeeding — Neuraxial labor analgesia is unlikely to affect breastfeeding, though existing literature
is insufficient to confirm this conclusion.

● Neonatal effects
○ In the absence of maternal hypotension prior to delivery, neuraxial analgesia and anesthesia do not
negatively affect the neonate.
○ There is no convincing evidence that epidural labor analgesia (ELA) causes autism, or that
choosing another form of pain relief for labor or no pain relief reduces the risk of autism or other
disabilities.
RESUMEN Y RECOMENDACIONES DEL ARTÍCULO

Las técnicas anestésicas y analgésicas neuroaxiales para el trabajo de parto y el parto están asociadas con
efectos secundarios y complicaciones. Algunos son más comunes que otros.

Efectos secundarios

● La hipotensión puede ocurrir principalmente como resultado del bloqueo simpático asociado con
el bloqueo neuroaxial y es más común durante la anestesia para el parto por cesárea que durante la
analgesia del trabajo de parto. Para la prevención de la hipotensión inducida por la anestesia neuroaxial
durante el parto por cesárea, para la mayoría de los pacientes sugerimos la administración profiláctica de
un vasopresor junto con coloides cristaloides intravenosos ( Grado 2C ). Administramos una fenilefrina
en dosis bajas infusión (es decir, a partir de 50 mcg / min) con bolos de rescate de fenilefrina, junto con
un bolo rápido de cristaloides intravenosos (500 a 1000 ml), en el momento de la inducción o la
colocación de la anestesia neuroaxial, con el objetivo de que la presión arterial materna se acerque al
valor inicial. Por lo general, la paciente se coloca con desplazamiento uterino izquierdo para evitar la
compresión aortocava.
● El prurito es un efecto secundario común de los opioides neuroaxiales y se trata de manera más
eficaz con la administración de una pequeña dosis de antagonista opioide (p. Ej., Naloxona [40 a 80 mcg
por vía intravenosa]), naltrexona (6 mg por vía oral) o el agonista opioide mixto. antagonista de la
nalbufina (2,5 a 5 mg por vía intravenosa [IV]).
● La fiebre intraparto, las náuseas y los vómitos, la retención urinaria y los escalofríos son otros
posibles efectos secundarios de la analgesia o la anestesia neuroaxial.

Complicaciones

● Las pacientes embarazadas tienen un mayor riesgo de dolor de cabeza posterior a la punción dural
(CPPD) que otros pacientes. La CPPD grave generalmente se trata con un parche sanguíneo epidural
(PBE).
● La toxicidad sistémica por anestésicos locales (LAST) es una complicación rara pero
potencialmente letal de la administración epidural de anestésicos locales. Las pacientes embarazadas
tienen un mayor riesgo de LAST cuando se administran dosis altas de un anestésico local de alta
concentración.
● La analgesia inadecuada, el bloqueo motor y el bloqueo neuroaxial alto son complicaciones que
pueden minimizarse mediante técnicas de manejo y elección de fármacos neuroaxiales.
● El hematoma epidural espinal es una complicación rara y potencialmente devastadora de las
técnicas de anestesia neuroaxial, que es más común en pacientes coagulopáticos, ya sea por medicación
anticoagulante, enfermedad sistémica o trombocitopenia. Para los pacientes con trombocitopenia,
realizamos anestesia neuroaxial en pacientes sin antecedentes de hemorragia con recuentos de plaquetas
estables por encima de 70.000 / microL. Para los pacientes con recuentos de plaquetas de 50.000 a 70.000
/ microL, realizamos anestesia neuroaxial si existe una razón de peso para hacerlo después del análisis de
riesgo-beneficio y preferimos una técnica espinal en lugar de una epidural.
● Las neuropatías posparto suelen tener causas obstétricas. En muy raras ocasiones, las
complicaciones neurológicas pueden ser el resultado de un traumatismo de la aguja o del catéter,
toxicidad por fármacos, hematoma epidural espinal o infección relacionada con las técnicas de anestesia
neuroaxial.
● Se debe seguir una técnica aséptica estricta durante las técnicas de anestesia neuroaxial, para
reducir el riesgo de meningitis y absceso epidural, que son complicaciones raras y graves.

Efectos fetales

● La analgesia neuroaxial puede afectar al feto directamente mediante la transferencia placentaria de

anestésicos locales u opioides, o indirectamente a través de efectos maternos (es decir, hipotensión o
hipertonía uterina). La transferencia placentaria de fármacos es rara con la administración de fármacos
epidurales o espinales en dosis bajas.
● En ausencia de hipotensión, puede ocurrir bradicardia fetal con un inicio repentino de la analgesia
y es más común después de la administración de opioides intratecal para la analgesia del trabajo de parto
que después del inicio de la analgesia epidural. La bradicardia fetal en este contexto suele ser transitoria y,
cuando se trata con las medidas habituales, no aumenta el riesgo de parto por cesárea o resultados
neonatales adversos.

Efectos sobre el progreso y el resultado del trabajo de parto : las técnicas de analgesia neuroaxial del
trabajo de parto de dosis baja administradas en cualquier momento durante el trabajo de parto no
aumentan el riesgo de parto por cesárea o parto instrumental. La analgesia neuroaxial puede acortar la
primera etapa del trabajo de parto y puede prolongar la segunda etapa del trabajo de parto en un grado
variable.

Lactancia materna : es poco probable que la analgesia neuroaxial del trabajo de parto afecte la lactancia
materna, aunque la literatura existente es insuficiente para confirmar esta conclusión.

Efectos neonatales

● En ausencia de hipotensión materna antes del parto, la analgesia neuroaxial y la anestesia no

afectan negativamente al recién nacido.
● No hay evidencia convincente de que la analgesia epidural durante el trabajo de parto (ELA) cause
autismo, o de que elegir otra forma de alivio del dolor para el trabajo de parto o ningún alivio del dolor
reduzca el riesgo de autismo u otras discapacidades.
OPINIONES

Susan Cali
El uso de la anestesia y analgesia en el parto es uno de los casos en los que más se tienen efectos
adversos. Los efectos secundarios son muy comunes, comenzando por la hipotensión que más se da en la
anestesia en el caso de parto por cesárea; prurito que se da comúnmente por los opioides neuroaxiales;
fiebre, náuseas, vómitos. Por otro lado, suelen darse varias complicaciones en pacientes embarazadas
tales como cefalea después de una punción dural, toxicidad sistémica por anestésicos locales, hematoma
epidurales espinales, neuropatías posparto ( estas dos últimas complicaciones son infrecuentes).
El artículo me pareció muy interesante debido a que nos explica cuales son las reacciones adversas,
complicaciones y efectos en pacientes obstétricos. Es necesario tener conocimiento de lo que estos
fármacos y su aplicación pueden ocasionar en un paciente en su condición, además de los efectos en el
neonato.

Manuel Calderón
Un aspecto que podemos recalcar de forma imperativa de este artículo es que, el proceso anestésico, para
aplicarse sobre una embarazada, debe tener el debido preparamiento previo, esto refiriéndose a tener un
conocimiento pleno y un control total sobre el estado y las condiciones clínicas de la paciente y el
producto, ya que de estas va a depender directamente el uso que se vaya a aplicar (y cómo se va a
aplicar), por ende, no está de más denotar que el proceso anestésico, en las pacientes embarazadas
(aunque también, en general), no puede ser un proceso autónomo, sino que debe llevar un debido proceso,
esto con la finalidad de que no perturbe el trabajo de parte y el parto como tal, ergo, el proceso anestésico
en una paciente embarazada va requerir de una adecuada valoración de lo que se puede aplicar, y lo que
necesita la paciente, ya que los efectos adversos (los riesgos), que pueden presentarse son lo
suficientemente significativos para considerar la aplicación de estos procesos anestésicos.

Emily Calderón
Este artículo se basa en los efectos adversos y las complicaciones que se presentan utilizando las técnicas
anestésicas y analgésicas neuroaxiales en el parto. Considero de suma importancia, tener en cuenta cuáles
son los motivos por el cual las pacientes pueden presentar este tipo de complicaciones, para así poder
evitarlas, es decir conocer la dosis adecuada, realizar una administración profiláctica y conocer la historia
clínica del paciente.
Existen efectos secundarios leves comunes que se presentan en los pacientes que se les administra
opioides neuroxiales como el prurito, en el cual el médico tratante debe tener conocimiento e
inmediatamente administrar dosis bajas de antagonistas opioides.
No solo la paciente que dará a luz puede presentar efectos secundarios, sino también el feto mediante la
transferencia placentaria de anestésicos, por eso es de vital importancia que el médico monitoree cada
cierto tiempo la estabilidad de ambos individuos. Así mismo, realizar estudios previos para descartar si
este tipo de técnicas pueden ser útiles en la paciente, y que sea seguro durante su progreso y resultado en
el parto.

Ma. Piedad Alvarado

De acuerdo al artículo leído, en este se presentan las diferentes técnicas analgésicas neuroaxiales y
anestésicas, entre ellas la espinal, epidural, epidural espinal combinada y epidural de punción dural, que
se usan para el trabajo de parto y para el parto como tal, las cuales son seguras, pero a la vez causan
diversos efectos adversos y complicaciones, ya sean para la paciente en parto y para el bebé.
Por lo tanto, debemos de tener en cuenta que al momento de aplicar alguna de las técnicas antes
mencionadas, se pueden presentar complicaciones como por ejemplo meningitis, aracnoiditis, entre otras,
además de presentan hipotensión, prurito, náuseas y vómito, y retención urinaria como efectos
secundarios. Es necesario recalcar que, para poner la anestesia adecuada, se debe de evaluar primero al
paciente que se someterá a esta técnica, ya que, de caso contrario, podría haber un bloqueo neuroaxial
fallido debido a la aplicación de una anestesia inadecuada, también este problema se puede dar por
factores del paciente como obesidad, o diferentes anomalías que se menciona en el artículo, por lo que es
muy importante valorar al indispuesto. Por lo que hay que tener mucho cuidado en la utilización de estas
técnicas debido a los problemas graves que pueden llegar a ocasionar

Karla Cedeño
Este artículo me pareció muy útil ya que nos da a conocer los diferentes puntos importantes de la
analgesia neuroaxial y la anestesia como efectos adversos, complicaciones, efectos fetales, efectos sobre
el progreso y resultado del parto, efectos sobre la lactancia materna, entre otros. Hay diferentes efectos
adversos en el uso de la analgesia y la anestesia neuroaxial, entre ellos cabe destacar la hipotensión que se
debe a la vasodilatación y a la disminución del retorno venoso al corazón, en el ámbito de la obstetricia la
hipotensión materna puede venir acompañada con síntomas maternos como el aturdimiento y náuseas y/o
deterioro de la frecuencia cardiaca fetal. Además, hay que tener en cuenta algo muy importante: la
anestesia espinal puede provocar una hipotensión más rápida a comparación con la anestesia epidural para
el parto por cesárea. Para evitar que suceda esto se incluye un bolo rápido de cristaloides intravenoso en
el momento de la colocación neuroaxial con vasopresores como por ejemplo la fenilefrina.

Meilin Amén
En base al articulo investigado previamente me gustaría recalcar la importancia de llevar a cabo un buen
procedimiento anestésico al momento del labor de parto o cesárea en una mujer grávida para evitar
agravar los efectos secundarios que pueden presentar ciertos analgesicos neuroaxiales donde se toma en
cuenta con mayor relevancia la hipotensión que puede presentar la paciente embarazada al momento de
una cesárea por lo cual para evitar este evento alarmante se emplea un método profiláctico de elección
que en estos casos sería administrar vasopresores junto con coloides cristaloides intravenosos. Otro
punto a tomar en cuenta es la aparición de prurito,fiebre, náuseas y vómitos en la paciente embarazada
donde en la actualidad se cuenta con protocolos farmacológicos para contrarrestar estos efectos
secundarios. Por lo demás también puede ocurrir complicaciones en el feto, cuyo dato interesante que me
llamó la atención fue la aparición de complicaciones neurológicas e incluso provocando un posible estado
de autismo en el niño, datos y estudios sobre este último tema no se han encontrado mucho por lo cual no
hay un respaldo garantizado, mas se ha planteado la posibilidad de que una mala técnica de analgesia
neuroaxial afecte de esta manera el feto y el futuro del mismo. Dichas razones expuestas previamente en
el artículo y en mi opinión personal considero de suma relevancia que se tome en cuenta el caso de la
paciente embarazada y se evalúan las técnicas que se vayan a usar en cada paciente previamente al labor
de parto para así evitar problemas en la paciente, en la lactancia y en el feto y su futuro.