Zulkifli, dr. SpAn.Mkes Depth.

Anesthesiology and Intensive Therapy FK Unsri/RSMH

KEY CONCEPTS
The most common morbidities encountered in

obstetrics are severe hemorrhage and severe preeclampsia all obstetric patients are considered to have a full stomach and to be at risk for pulmonary aspiration. Regional anesthetic techniques are preferred for management of labor pain.

 Using a local anestheticopioid mixture for lumbar

epidural analgesia during labor significantly reduces drug requirements Optimal analgesia for labor requires neural blockade at T10L1 in the first stage of labor and T10S4 in the second stage. Continuous lumbar epidural analgesia is the most versatile and most commonly employed technique

 dilute mixtures of a local anesthetic and an opioid are

used epidural analgesia has little if any effect on the progress of labor Hypotension is the most common side effect of regional anesthetic techniques and must be treated aggressively Spinal or epidural anesthesia is preferred to general anesthesia for cesarean section

 Spinal anesthesia for cesarean section is easier to

perform and results in more rapid and intense neural blockade than epidural anesthesia

 the life of the mother takes priority over delivery of the

fetus Maternal hemorrhage is one of the most common severe morbidities complicating obstetric anesthesia. Pregnancy-induced hypertension describes one of three syndromes: preeclampsia, eclampsia, and the HELLP syndrome.

 Common causes of postpartum hemorrhage include

uterine atony, a retained placenta, obstetric lacerations, uterine inversion, and use of tocolytic agents prior to delivery. Intrauterine asphyxia during labor is the most common cause of neonatal depression

Anesthetic Risk in Obstetric Patients

Incidence of Severe Obstetric Morbidity

Morbidity Severe hemorrhage Severe preeclampsia HELLP syndrome Severe sepsis Eclampsia Uterine rupture Incidence per 1000 6,7 3,9 0.5 0,4 0,2 0,2

Anesthetic Mortality
Anesthesia accounts for approximately 23% of maternal

deaths. 32 deaths per 1,000,000 live births due to general anesthesia 1.9 deaths per 1,000,000 live births due to regional anesthesia. Recent : maternal mortality from anesthesia (about 1.6 deaths per 1,000,000 live births), possibly due to greater use of regional anesthesia for labor and cesarean section. the risk greater with emergency than with elective cesarean sections.

General Approach to the Obstetric Patient

All patients potentially require anesthesia, whether planned or emergent. should be aware of the presence and relevant history of all patients. include age, parity, duration of the pregnancy, and any complicating factors. requiring anesthetic care (for labor or cesarean section) should undergo a focused preanesthetic evaluation. maternal health history, anesthesia-related

obstetric history, blood pressure measurement, airway assessment, and back examination for regional anesthesia.

 All women in true labor should be :

managed with intravenous fluids (usually lactated Ringer's injection with dextrose) to prevent

dehydration. An 18-gauge or larger intravenous catheter is employed Blood should be sent for typing and screening in patients at high risk for hemorrhage or with a borderline acceptable hematocrit. full stomach and to be at risk for pulmonary aspiration. Patients at high risk for an operative delivery should take nothing by mouth.

 Prophylactic administration of a clear antacid (1530 mL of 0.3 M sodium citrate orally) every

3 h can help maintain gastric pH greater than 2.5 and may decrease the likelihood of severe aspiration pneumonitis. An H2-blocking drug (ranitidine, 100150 mg orally or 50 mg intravenously) or metoclopramide, 10 mg orally or intravenously, should also be considered in high-risk patients. The supine position should be avoided unless a left uterine displacement device (> 15 wedge) is placed under the right hip.

Anesthesia for Labor & Vaginal Delivery

Psychological & Nonpharmacological Techniques Patient education and positive conditioning about the birthing process Parenteral Agents
Pudendal Nerve Block Regional Anesthetic Techniques

Spinal Opioid Dosages for Labor and Delivery

Agent
Morphine Meperidine Fentanyl Sufentanil

Intrathecal
0.250.5 mg 1015 mg 12.525 g 310 g

Epidural
5 mg 50100 mg 50150 g 1020 g

Local Anesthetic/Local Anesthetic Opioid Mixtures

Lumbar Epidural Anaglesia
Although local anesthetics can be used alone, there is

rarely. The higher concentration of local anesthetic required (eg, bupivacaine 0.25% and ropivacaine 0.2%) can impair the parturient's ability to push effectively as the labor progresses. Bupivacaine or ropivacaine in concentrations of 0.06250.125% with either fentanyl 23 g/mL or sufentanil 0.30.5 g/mL is most often used.

 the lower the concentration of the local anesthetic the

higher the concentration of opioid that is required. Very dilute local anesthetic mixtures (0.0625%) generally do not produce motor blockade and may allow some patients to ambulate ("walking" or "mobile" epidural). The long duration of action of bupivacaine makes it a popular agent for labor. Ropivacaine may be preferable because of possibly less motor blockade and its reduced potential for cardiotoxicity

Epidural Activation for the First Stage of Labor

Administer a 500- to 1000-mL intravenous

bolus of lactated Ringer's injection while the epidural catheter is being placed. Test for unintentional subarachnoid or intravascular placement of the needle or catheter

 Give 10 mL of the local anestheticopioid

mixture in 5 mL increments Monitor until the patient is stable Repeat steps 3 and 4 when pain recurs until the first stage of labor is completed

Epidural Activation during the Second Stage of Labor

Give a 500- to 1000-mL intravenous bolus of lactated Ringer's injection.
If the patient does not already have a catheter in

place, identify the epidural space while the patient is in a sitting position. A patient who already has an epidural catheter in place should be placed in a semiupright or sitting position prior to injection.

 Give a 3-mL test dose of local anesthetic (eg, lidocaine 1.5%) with 1:200,000 epinephrine. Again the injection should be between contractions.
give 1015 mL of additional local anestheticopioid mixture at a rate not faster than 5 mL every 12 min. Administer oxygen by face mask and lay the patient supine with left uterine displacement and monitor

Management of Complications
Hypotension
Unintentional Intravascular Injections Unintentional Intrathecal Injection Postdural Puncture Headache (PDPH) Maternal Fever

Combined Spinal & Epidural (CSE) Analgesia

particularly benefit patients with severe pain early in

labor and those who receive analgesia/anesthesia just prior to delivery. Intrathecal opioid and local anesthetic are injected and an epidural catheter is left in place. The intrathecal drugs provide almost immediate pain control and have minimal effects on the early progress of labor, whereas the epidural catheter provides a route for subsequent analgesia for labor and delivery or anesthesia for cesarean section.

 Addition of small doses of local anesthetic

agents to intrathecal opioid injection greatly potentiates their analgesia and can significantly reduce opioid requirements. inject 2.5 mg of preservative-free bupivacaine or 34 mg of ropivacaine with intrathecal opioids for analgesia in the first stage of labor.

 Intrathecal doses for CSE are fentanyl 45 g or

sufentanil 23 g. Addition of 0.1 mg of epinephrine prolongs the analgesia with such mixtures but not for intrathecal opioids alone. Some studies suggest that CSE techniques may be associated with greater patient satisfaction than epidural analgesia alone. A 24- to 27-gauge pencil-point spinal needle (Whitacre, Sprotte, or Gertie Marx) is used to minimize the incidence of PDPH.

Spinal Anesthesia (ILA)

given just prior to delivery
Also known as saddle blockprovides profound

anesthesia for operative vaginal delivery. A 500- to 1000-mL fluid bolus is given prior to the procedure, which is performed with the patient in the sitting position. Use of a 22-gauge or smaller, pencil-point spinal needle (Whitacre, Sprotte, or Gertie Marx) decreases the likelihood of PDPH.

 Hyperbaric tetracaine (34 mg), bupivacaine (67 mg), or

lidocaine (2040 mg) usually provides excellent perineal anesthesia. Addition of fentanyl 12.525 g or sufentanil 57.5 g significantly potentiates the block. A T10 sensory level can be obtained with slightly larger amounts of local anesthetic. The intrathecal injection should be given slowly between contractions to minimize excessive cephalad spread. Three minutes after injection, the patient is placed in the lithotomy position with left uterine displacement.

Anesthesia for Cesarean Section Major Indications for Cesarean Section

Labor unsafe for mother and fetus Increased risk of uterine rupture Previous classic cesarean section Previous extensive myomectomy or uterine reconstruction Dystocia Immediate or emergent delivery necessary Fetal distress Umbilical cord prolapse Maternal hemorrhage Abnormal fetopelvic relations Fetopelvic disproportion Abnormal fetal presentation

Increased risk of maternal hemorrhage

Central or partial placenta previa

Transverse or oblique lie

Breech presentation

Amnionitis
Genital herpes with ruptured membranes Impending maternal death

Abruptio placentae Previous vaginal reconstruction

Dysfunctional uterine activity

REGIONAL ANESTHESIA
Cesarean section requires a T4 sensory level. receive a 1000- to 1500-mL bolus of lactated Ringer's

injection prior to neural blockade. Crystalloid boluses do not consistently prevent hypotension but can be helpful in some patients. Smaller volumes (250500 mL) of colloid solutions more effective. supplemental oxygen (4050%) is given blood pressure is measured every 12 min until it stabilizes.

 Intravenous ephedrine, 10 mg, should be used to

maintain systolic blood pressure > 100 mm Hg. Hypotension following epidural anesthesia typically has a slower onset. Slight Trendelenburg positioning facilitates achieving a T4 sensory level and may also help prevent severe hypotension. Extreme degrees of Trendelenburg interfere with pulmonary gas exchange.

ADVANTAGES
REGIONAL ANESTHESIA
less neonatal exposure to

GENERAL ANESTHESIA
very rapid and reliable onset control over the airway and

drugs decreased risk of maternal pulmonary aspiration awake mother at the birth of her child using spinal opioids for postoperative pain relief.

ventilation less hypotension facilitates management in the event of severe hemorrhagic complications

Regional Anesthesia
SPINAL ANESTHESIA
placed in the lateral

EPIDURAL ANESTHESIA
generally most satisfactory excellent route for

decubitus or sitting position hyperbaric solution injected Adding 12.525 g of fentanyl or 510 g of sufentanil Continuous spinal anesthesia

postoperative opioid administration total of 1525 mL of local anesthetic is injected slowly in 5-mL increments

CSE Anesthesia
CSE is combined spinal epidural analgesia.
the benefit : rapid Reliable intense blockade of spinal anesthesia with the flexibility of an epidural catheter. The catheter can be used for postoperative analgesia. As mentioned previously, drugs given epidurally should be administered and

titrated carefully

General Anesthesia Technique for Cesarean Section

patient is placed supine Preoxygenation is with 50% NO2 in O2 with up to

100% oxygen patient is prepared and draped for surgery a rapid-sequence induction with cricoid pressure Surgery is begun only after placement of ETT is confirmed

0.75 MAC of a volatile agent After the neonate and placenta are delivered, 20 30 U of oxytocin is added Methergine 0.2 mg intramuscularly aspirate gastric contents via an oral gastric tube reversed

PPGD untuk perawat dan dokter 4-9 Agustus 2008