Anesthesia for Normal Labor and Delivery

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McGill Pain Questionnaire

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(Melzack R: The myth of painless childbirth. Pain 19:321, 1984)

Analgesia for Labor and Delivery

Always controversial! Birth is a natural process Women should suffer!! Concerns for mothers safety Concerns for baby Concerns for effects on labor

John Snow (1853) on Queen Victorias Anesthetic for the birth of Prince Leopold:
The inhalation lasted fifty-three minutes. The chloroform was given

on a handkerchief in fifteen minim

doses; the Queen expressed herself

as greatly relieved by the

administration.

The Ideal Labor Analgesic

Good pain relief No autonomic block (no hypotension) No adverse maternal or neonatal effects No motor block No effect on labor and delivery:
No increase in C/S rate No increase in forceps/vacuum delivery

Patient can ambulate Economical: cost and personnel

Pain Pathways in Labor and Delivery

Eltzschig, Leiberman, Camann, NEJM 348; 319:2003

Labor Pain at different Stages of Labor

Eltzschig, Leiberman, Camann, NEJM 348; 319:2003

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Fetal pH during Labor and Delivery

pH

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Analgesia for Vaginal Delivery

Systemic narcotics Tranquilizers / hypnotics Inhalation analgesia Acupuncture TENS Psychoanalgesic techniques

Placental Transfer of Drugs:

Maternal, Drug, Placental and Fetal Factors

Lipid solubility

Molecular size
Total dose of drug Concentration gradient

Maternal metabolism and excretion

Degree of ionization pKa of drug, maternal and fetal pH Protein binding - mother and fetus Uterine blood flow Time for equilibrium to occur

Factors Determining Fetal Drug Levels

(Ralston, 1987)

Differential Protein Binding

Differential maternal and fetal protein binding accounts for differences in total circulating drug concentrations on both sides of placenta, when free drug concentrations are actually equal

UV/MV Fetal-Maternal Drug Ratios

Bupivacaine:

0.25-0.3

Mepivacaine:
Lidocaine:

0.7
0.5

Correlates with degree of protein binding, but may not reflect total amount of drug in

fetus because of high lipid solubility

leading to significant tissue uptake

Local Anesthetics - Ionic Trapping

Mother (normal acid-base) pH = 7.40
Placental Membrane Fetus (acidosis) pH = 7.00

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(2.4)

(1)

(1)

(6)

From the American College of Obstetricians and Gynecologists, Obstet Gynecol 1976; 48:29)

Systemic Opioids in Labor

Advantages:

Easy administration
Inexpensive No needles Avoids complications of regional block Does not require skilled personnel

Few serious maternal complications

Perceived as natural

Systemic Opioids in Labor

Disadvantages:

All drugs easily cross placenta

Pain relief inadequate in most cases

Maternal sedation Nausea, vomiting, gastric stasis Fetal heart rate effects:
Loss of beat-to-beat variability Sinusoidal rhythm

Dose-related maternal / neonatal depression Newborn neurobehavioral depression

Which Systemic Opioid?

Pure Agonists

Morphine:

long half-life, neonatal depression Meperidine: neonatal depression (normeperidine effect) nausea, vomiting Fentanyl: short duration, minimal newborn effects Alfentanil: newborn depression Remifentanil? (what surveillance is needed?)

IV-PCA Fentanyl during Labor

A suggested regimen:

Loading dose of 50-100 mcg No background infusion

10-12.5 mcg bolus

8-10 min lockout

4 hour limit - 300 mcg

Pulse oximeter if large doses given

Visual Analog Pain Scores with Systemic Opioids During Labor

10 10 8 8

VAPS during Labor

6 6 4 4 2 2 0 0

Meperidine Fentanyl

4-7 cm

8-10 cm

(Data (Data from from Rayburn Rayburn et et al. al. Obstet Obstet Gynecol Gynecol 1989;14:604) 1989;14:604)

Serum Fentanyl Concentrations vs. Maternal Dose During Labor

0.5 0.5 0.4 0.4 Serum Serum Fentanyl Fentanyl 0.3 0.3 (ng/ml) (ng/ml) 0.2 0.2 0.1 0.1 0 0 50 50 100-200 100-200 > > 200 200 Maternal Maternal Fentanyl Fentanyl Dose Dose During During Labor Labor (g) (g)
(Data (Data from from Rayburn Rayburn et et al. al. Am Am J J Obstet Obstet Gynecol Gynecol 1989;161:202) 1989;161:202)

Maternal Maternal Umbilical Umbilical

Which Systemic Opioid?

Agonist-Antagonists
Ceiling effect for respiration and analgesia
Maternal sedation prominent

Nalbuphine
Butorphanol

Buprenorphine

Potential Fetal/Neonatal Effects of Maternal Sedation

Low 1 and 5 min Apgar scores Respiratory acidosis

Naloxone, ventilatory assistance may be needed

Neurobehavioral depression - dose dependent

Prolonged observation in NICU occasionally needed

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Neurologic and Adaptive Capacity Score (NACS)

(Anesthesiology, 1982)

Neonatal Neurobehavioral Effects of Maternal Systemic Medication

Transient, global depression of behavior related to presence and quantity of drug in newborn

Most effects gone by 3rd day; all by 10 days Important to differentiate from sinister causes

Inhalation Analgesia for Vaginal Delivery

(N2O 30-50%; very low concentration volatile agents)

Advantages:

Easy to administer (no needles or PDPH) Satisfactory analgesia variable Minimal neonatal depression

Inhalation Analgesia for Vaginal Delivery

(N2O 30-50%; very low concentration volatile agents)

Disadvantages:

Decreased uterine contractility (except N2O) Rapid induction of anesthesia in pregnancy Risk of unconsciousness and aspiration Difficulties with scavenging in labor rooms

Analgesia for Labor and Delivery

Local and regional techniques

Local infiltration
Pudendal block Paracervical block Paravertebral (lumbar sympathetic block) Epidural - lumbar (caudal) Spinal Combined spinal-epidural (CSE)

Analgesic Blocks for Labor and Delivery

Paracervical Block

Regional Analgesia for Labor

Lumbar epidural

Segmental (T10-L1) Extended (T10-S5)

Caudal epidural (S5-T10) Spinal (LA opioids)

CSE (opioids LA)

Fetal / Neonatal Effects of Regional Analgesia in Labor

Uterine perfusion maintained

Profound hypotension possible fetal compromise

LA toxicity - extremely rare FHR changes:
baseline variability periodic decelerations (due to maternal catechols?)

Apgar scores, acid-base status, unaffected Neurobehavioral effects absent with current agents

The Ideal Labor Analgesic

Good pain relief No autonomic block (no hypotension) No adverse maternal or neonatal effects No motor block No effect on labor and delivery:
No increase in C/S rate No increase in forceps/vacuum delivery

Patient can ambulate Economical: cost and personnel

How to Achieve Goals:

What you put in:

Drugs, concentrations, combinations

How you deliver it:

Intermittent boluses, continuous, PCEA

How much you give:

Low vs. high infusion rates

Local Anesthetic

Opioids

Analgesia for Labor

Bicarbonate New spinal agonists Alpha-2-agonists

Choice of Epidural Local Anesthetic

Lidocaine:
rapid rapid onset, onset, dense dense motor motor block, block, risk risk of of cumulative cumulative toxicity toxicity with with repeated repeated doses doses

Chloroprocaine:
rapid rapid onset, onset, low low toxicity, toxicity, dense dense block, block, antagonizes antagonizes bupivacaine bupivacaine and and opioids opioids

Bupivacaine:
good good sensory, sensory, minimal minimal motor motor block, block, no no adverse adverse effect effect on on labor labor with with 0.0625% 0.0625%

Ropivacaine:
lower lower toxicity, toxicity, ? ? less less motor motor block, block, less less potent potent

Levobupivacaine: lower lower toxicity toxicity

Ropivacaine vs. Bupivacaine in Labor What are the Relative Potencies?

Ropivacaine is only 60% as potent as bupivacaine

(2 MLAC studies*)

Claims for reduced toxicity and motor block must consider relative potency

Do very dilute agents pose risk of toxicity? Newer agents very expensive

(*Polley et al. Anesthesiology, 1999. Capogna et al. BJA, 1999)

Relative Analgesic and Motor Blocking Potencies of Epidural Bupivacaine and Ropivacaine in Labor

(Lacassie et al. Anesth Analg 2002;95:204)

Relative Motor Blocking Potencies of Epidural Bupivacaine and Ropivacaine

CONCLUSIONS

Motor block potency ratio is the same as sensory block potency ratio Ropivacaine is only 0.66 as potent as bupivacaine

No difference in mode of delivery

(Lacassie et al. Anesth Analg 2002;95:204)

Potencies of Levobupivacaine and Bupivacaine in Labor

Lyons et al. Br J Anaesth 1998;81: 899

Epinephrine Use in Labor

May transiently slow labor

Increases motor block

Improves analgesia ( 1:600K works) Epinephrine test dose often avoided in labor

Low specificity - maternal heart rate very variable Low sensitivity - response to sympathomimetics Increases motor block - prevents ambulation Potential for UBF with repeated doses Very dilute agents - whole first dose is test dose.

Epidural Opioids in Labor

Inadequate analgesics used alone Synergize with local anesthetics Speed onset of analgesia Improve quality of analgesia

Permit use of very dilute LA solutions

Help relieve persistent perineal pain and unblocked segments

Optimal recipe and maximum safe dose not

determined

WHICH EPIDURAL OPIOID?

Morphine (2 mg) Meperidine (25-100 mg) Butorphanol (1-2 mg)
Risk Risk of respiratory depression Pruritus Pruritus ++ Ineffective alone Neonatal Neonatal effects with larger doses. doses. Local anesthetic effect Somnolence, dysphoria with larger doses

Which Epidural Opioid in Labor?

Fentanyl and Sufentanil

Rapid onset, few side effects Sufentanil slightly more effective

No significant fetal drug accumulation (? less

with sufentanil)

No serious adverse neonatal effects with either

Light or Ultra-light Analgesic Techniques

Bupivacaine Ropivacaine Levobupivacaine

OPIOID

Continuous Infusion Epidural

A larger volume of a more dilute agent is more effective for labor analgesia than a smaller volume of higher concentration

PCEA
Good analgesia Patient autonomy Less need for MD interventions Cost effective

Effect of Low-Dose Mobile vs. Traditional Epidural Techniques on mode of delivery: A randomized Trial
(Comet Study UK , Lancet 2001;358:19)
50

% Patients

40 30 20 10 0 "Traditional"
Bupivacaine 0.25%

Spontaneous Instrumental C/Section

CSE
Bupiv 2.5 mg + Fent 25 mcg

Low-dose Infusion
Bupivacaine 0.1% + fentanyl

Effect on Instrumental Vaginal Delivery Rate of Continuing Epidural Infusion During the Second Stage of Labor
0.125% 0.125% bupivacaine bupivacaine vs. vs. 0.0625% 0.0625% bupivacaine bupivacaine + +2 2 g/ml g/ml fentanyl fentanyl Infusion Infusion continued continued Infusion Infusion discontinued discontinued

60 60 40 % % Instrumental Instrumental 40 Delivery Delivery 20 20 0 0

53 53

*
28 28

21 21 15 15

0.125%Bup 0.125%Bup

0.0625% 0.0625% Bup Bup + + fentanyl fentanyl

(Chestnut (Chestnut et et al. al. 1987, 1987, 1990) 1990)

Ultra-Light Bupivacaine-Sufentanil PCEA technique for Labor Analgesia

(Stanford Technique)

Block initiated with 15-20 ml bolus: 0.125% bupivacaine + sufentanil 10 mcg

PCEA solution:

0.0625% bupivacaine + sufentanil 0.3-0.4 mcg/ml

PCEA settings: Basal infusion: 10-15 ml/hour Bolus: 12 ml Lockout: 15 min

Physician Administered Boluses

100 80 60 % Pts 40 20 0 Gp A No boluses Gp B 1 bolus Gp C >1 bolus Gp D

IT Opioid Analgesia (CSE)

Advantages of CSE (opioids local anesthetic) for Labor Analgesia

Rapid onset of intense analgesia (the patient loves you immediately! )

Ideal in late or rapidly progressing labor Very low failure rate Less need for supplemental boluses

Minimal motor block (walking epidural)

Side effects vs standard epidural?

Median Upper and Lower Level of Decreased 10 g Pinprick Sensation after Intrathecal Sufentanil 10 g

(Cohen et al. Anesth Analg, 1993)

Duration of Intrathecal Opioid Analgesia in Labor

Morphine Morphine + + Fentanyl Fentanyl Morphine Morphine + + Sufentanil Sufentanil Fentanyl Fentanyl Sufentanil Sufentanil Sufentanil Sufentanil + + Epi Epi Fentanyl Fentanyl + + Bup Bup Sufentanil Sufentanil + + Bup Bup Fentanyl Fentanyl + + Bup Bup + + Epi Epi Sufentanil Sufentanil + + Bup Bup + + Epi Epi
0 0 50 50 100 100 (min) (min) 150 150 114 114 188 188 200 200 90 90 108 108 148 148 90 90 100 100 114 114 134 134

(Data (Data from from multiple multiple sources) sources)

Onset of Analgesia: CSE vs. Epidural

Collis et al. Lancet 1995;345:1413

100 75

CSE Epidural

VAPS (0-100)

50 25 0 Baseline 5 10 15 20

Time (minutes)

Complications of IT Opioid or CSE Analgesia in Obstetrics

Rare but Serious Problems
Severe hypotension Respiratory depression High sensory block Severe fetal bradycardia Infection

The Problem

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Figure 1. Cardiotocogram (1 cm/min) showing: 1) typical uterine hyperactivity with fetal distress, 2) administration of g administered), 3) resolu tion o f the hyperactivity with normalization of fetal heart intravenous nitroglycerin (arrow, 90 ra te, and 4) rapid rea ppearan ce of regular uterine a ctivity. Anesth An alg 1997; 84 :1117 20

Journal Conte nt Copyright 1991-Pre se nt, ASA, IARS, BJA, CAS. All Rights Re se rv e d. Re pr oduction of said mate r ial, without prior pe rmission fr om the Proprie tor holding the copyright to the mate r ial, is ille gal.

Epinephrine Levels after Analgesia

Cascio et al. Can J Anaesth 1997; 44:605-609

Fetal Bradycardia After Labor Analgesia

Pain Relief Decreased Circulating Epinephrine Increased Uterine Tone Decreased Uterine Blood Flow Fetal Bradycardia

Fetal Heart Rate Changes after Analgesia: CSE vs. Epidural

30

CSE Epidural
20

%
10

*
0 Nielsen Palmer Riley Eberle

Nielsen et al. Anesth Analg 1996; 83:7426 Palmer et al. Anesth Analg 199;88(3):577-81 Riley et al. Anesthesiology 1999; A1054 Eberle et al. Am J Obstet Gynecol 1998; 179:150-155

Fetal Heart Rate after CSE - Selection Bias May Contribute to Higher Incidence of Fetal Bradycardia Riley...Cohen et al. Anesthesiology 1999; A1054

20

* *
CSE Epidural

15

10

0 Fetal Bradycardia Uterine Hypertonus

Fetal Bradycardia = FHR < 120 bpm for > 2min

Greater Pain Scores and Cervical Dilation Before Analgesia May Contribute to Bias
Riley...Cohen et al. Anesthesiology 1999; A1054
10

*
8 6

Epidural CSE

(n = 196)

*
4

0 Cervical Dilation Baseline Pain Score

Management of FHR Changes

Left uterine displacement Maternal position change

O2 administration

STOP OXYTOCIN!
Fetal scalp stimulation Nitroglycerin: 400 g sublingual X 2 (or more) 100 g IV repeated as needed

Terbutaline 0.25 mg, subcutaneous Treat hypotension Ephedrine - epinephrine level; UBF

Complications of IT Opioid or CSE Analgesia in Obstetrics

Other Problems Analgesic failure: needle too short needle deviates from midline drug inadequate

Drug mixing errors Post dural puncture headache Pruritus Nausea/vomiting

Spinal Needle Design

Riley, Cohen et al.

Obtain CSF? Success Failure

120 mm Needle 83% 17% *

127 mm Needle 100% 0%

* Longer needle subsequently successful in all these cases.

CSE vs. Epidural Labor Analgesia: Risk of Headache

Norris et al, Anesthesiology 2001;95:913

2.0 1.6 % Patients 1.2 0.8 0.4 0.0 Dural Puncture Headache EBP

CSE Epidural
(n=2183)

Strategies to Decrease Complications with CSE

Decrease dose of opioid:

Fentanyl 15-20 g Sufentanil 2.5-5 mg

Combine with:
Local anesthetic (bupivacaine 1.25-2.5 mg) Epinephrine? Clonidine? (Neostigmine?)

Current Recommendations for CSE

Use lowest effective dose of opioid, dont repeat Monitor BP, FHR, Respiration, (SpO2 if indicated) Expect potentiation of epidural doses

All mixtures hypobaric - avoid prolonged sitting

position after block

Treat hypotension and uterine hypertonus Naloxone and resuscitation equipment available Same or greater surveillance as after epidural

Controversial Areas

Effects on labor and delivery process

Maternal temperature elevation Drug choice - are new agents better?

Epidural vs. CSE

Conclusions

Individualize technique to patients goals

and stage of labor Optimize management for spontaneous delivery Provide safe, cost-effective analgesia