Nina Ian John “G” Chel Mark Ivz Jobe Jocelle Edo Gienah Jho Kath Aynz Je Glad

Nickie Rico Teacher Dang Niňa Arlene Vivs Paulfie Rico F. Ren Mai Revs Mavis Jepay Yana Mayi Serge Hung Tope Ag Bien

S2 Lec 3 (1 of 2): Anesthesia by Dra. Alicia Bautista AAuugguusstt 2233,, 22001100

2. Respiratory Mechanism
ANESTHESIA
 Enlarging uterus produces upward displacement of diaphragm
Physiological Changes during Pregnancy with Major Clinical  dec FRC 15% (thus induction of inhalation anesthesia is
Anesthetic Implication faster)
A. Cardiovascular System  Dec inhalation anesthesia required
 Dec FRC + inc O2 consumption = predisposes the parturient to
1. Increased Cardiac Output produces hyperdynamic state  inc limited o2 reserve  rapid development of hypoxemia +
workload  predisposes to functional murmur hypercarbia during periods of apnea

 Healthy female can tolerate the hyperdynamic state C. Gastrointestinal

 Gravid with heart disease  inc workload precipitate
pulmonary congestion especially during labor to  Inc progesterone – dec gastric motility, dec food absorption
immediately postpartum  inc CO maximal  Inc gastrin level (of placental origin) – more acidic gastric
 Provide effective analgesia – continuous lumbar epidural content
analgesia  Enlarged uterus – inc intragastric pressure  dec normal
oblique angle in the gastroesophageal junction
2. Increased blood volume  Pregnant patient should always be considered to have a full
stomach irrespective of time of last meal. Why? Gastric
 Inc in plasma blood volume emptying decreases so be very particular of last intake of your
▫ 40-50% inc plasma volume patient
▫ 15-20% inc red cell volume  General anesthesia should always be avoided when possible
 Physiologic anemia as they are at risk for aspiration of gastric contents
▫ Double-edged sword
▫ Inc clotting factor protects patient from blood loss and Pain Mechanism in Labor
renders her hypercoagulable – inc risk of thrombotic
events 1. Pain during 1st stage labor
▫ After delivery – ask patient to ambulate
 Arises from uterus and adnexae during contraction
3. Aortocaval syndrome  Mediated by T10-L1 spinal segment
 Visceral in nature
 Supine position  uterus is compressed against the  Characteristics: dull, diffuse, periodic and build peaks
vertebral column  impaired venous return  bradycardia
and decrease BP 2. Pain during 2nd stage labor
 SUPINE HYPOTENSIVE POSITION
▫ Results from a drop in venous return for which CVS  Results from distention of birth canal, vulva and perineum
cannot compensate  Mediated by afferent fibers of posterior roots of S2-S4 nerve
▫ Sympathetic blockade due to spinal or epidural  Somatic in character: well localized, sharp and definitive,
anesthesia will interfere with the mechanism to often constant
compensate for aortocaval compression  profound *sabi ni doc…S.S.S. (Second stage, S2-S4)
hypotension
 At risk for aortocaval compression are those with
Methods of Pain Relief
large uterus (multiple gestation, polyhydramnios,
DM)
1. Non-pharmacologic
B. Respiratory System a. Childbirth education
i. Lamaze
b. Mind-body intervention
1. Upper airway
i. Hypnosis
ii. Biofeedback
 Generalized peripheral edema iii. Music therapy
 Increase vascularity of the respiratory tract mucosa c. Bioelectromagnetics
 Capillaries engorged i. Transcutaneous nerve stimulation
 In labor, airway is edematous with voluntary and d. Intracutaneous nerve stimulation
involuntary valsalva maneuver i. Sterile water blocks
 Preeclampsia ii. Acupuncture
▫ irway edematous + friable bleeding e. Manual healing
▫ difficulty intubation should be considered i. Therapeutic pouch
ii. Massage therapy
iii. Muscle tension release

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 iv. Reflexology  Saddle block
v. Acupressure systems  Modified spinal block
vi. hydrotherapy  Affects only the sacral segment
f. Herbal medicine  Ideal for completion of 2nd stage labor
i. Herbal cocktails ANESTHESIA FOR CAESARIAN SECTION
ii. Aromatherapy
Regional Anesthesia
2. Pharmacologic methods  Preferred technique because mother remains awake and is able to
a. Systemic bond with her newborn upon delivery
i. Opioids  2 most common regional techniques:
 the more lipid soluble is, the more freely it can  Spinal or Subarachnoid anesthesia
pass through and are associated with risk of  More commonly used in the Philippines during CS
neonatal respiratory depression and delivery
neurobehavioral changes  Simpler, more reliable with lesser chances of failure,
ii. Sedative and/or tranquilizers faster onset of action, requires lesser drug dosage
 Phenothiazines thus minimizing the risks of local anesthetic toxicity
 Benzodiazepins and drug transfer to the fetus
iii. Dissociative medications - ketamine  Hypotension: most common side effect
iv. Barbiturates (Tx: uterine displacement, IV hydration, ephedrine)
v. Propofol
 Other complications: spinal headache, high spinal
vi. Inhalational
block and failed regional block
 causes dose-dependent relaxation of uterine
smooth muscle
 high dose relaxes the uterus  Epidural anesthesia
 Less severity and incidence of hypotension
 It avoids dural puncture which may diminish the
b. Regional
incidence of spinal headache
 With epidural catheter in place duration of anesthesia
Peripheral Blocks for Labor Analgesia can be prolong
 Requires high drug doses, delayed onset of action
i. Perineal Infiltration prone to patchy or incomplete blockade
 Gold Standard: for pain relief during ALL stage of
 Most common local anesthetic technique labor
for vaginal delivery, mainly for episiotomy
and repair  Absolute contraindications:
 Lidocaine 5-10cc  Refractory maternal hypotension
 Maternal coagulopathy
ii. Pudendal nerve block  Treatment with once daily dose of low molecular weight
heparin within 12 hrs
 Involves injection of total 7-10 mL each local  Untreated bacteremia
anesthetic into the right and left pudendal  Skin infection over site of needle placement
nerve as it passes medially to and posterior to  Increased in the intracranial pressure caused by mass
the ischial spine in each side of the pelvis lesion
 Goal: to block the pudendal nerve distal to its
formation by the anterior division of S2-S4 but The Choice of Anesthetic Technique
proximal to its division into its terminal - depends on three important factors:
branches 1. indication of pain relief
 Adequate for spontaneous delivery and outlet 2. condition of mother and baby
forceps delivery 3. skill of the anesthesiologist
 Lidocaine

iii. Paracervical block

 Blocks impulses from uterine body and cervix

 Aim: block transmission through the
paracervical ganglion (Frankenhauser’s
Brought to you by: OBwan-Kenobi
Ganglion) which lies immediately lateral and
(RPE-JCF-PF-SAH)
posterior to the cervicouterine junction
 Lidocaine injected to the cervix laterally 3 and
“With OBwan-Kenobi, everyone can OB” :D
9 o’clock position
 Complication: fetal bradycardia

iv. Neuraxial

 Spinal
 Epidural
 Combined spinal-epidural
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