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In The Name of GOD

In The Name of GOD. M. A. Attari , MD. Associated Professor of Anesthesiology Medical University Of Isfahan ma_attari@yahoo.com. Obstetric analgesia for normal delivery and anesthesia methods for Cesarean section in Isfahan-IRAN.

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In The Name of GOD

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  1. In The Name of GOD M. A. Attari, MD. Associated Professor of Anesthesiology Medical University Of Isfahan ma_attari@yahoo.com

  2. Obstetric analgesia for normal delivery and anesthesia methods for Cesarean section in Isfahan-IRAN

  3. In our province approximately 60% of parturient get delivery by cesarean section, while in the our country as a whole is 46% and in south east of IRAN in Zabol near to the Pakistan is about 4%.

  4. The usual methods of analgesia for Vaginal Delivery is: • Inhalation analgesia • Systemic narcotics • Tranquilizers / hypnotics • Acupuncture • TENS • Psychoanalgesictechniques

  5. TECHNIQUES OF LABOR ANALGESIA Continuous epidural analgesia Patient-controlled epidural analgesia (PCEA) Combination of the above two techniques Combined spinal-epidural analgesia (CSE) Spinal opiates Intermittent epidural bolus injections

  6. Inhalation Analgesia for Vaginal Delivery Advantages: • Easy to administer (no needles or PDPH) • “Satisfactory” analgesia variable • Minimal neonatal depression (N2O 30-50%; very low concentration volatile agents)

  7. Inhalation Analgesia for Vaginal Delivery Disadvantages: • Decreased uterine contractility (except N2O) • Rapid induction of anesthesia in pregnancy • Risk of unconsciousness and aspiration • Difficulties with scavenging in labor rooms (N2O 30-50%; very low concentration volatile agents)

  8. Pain Relief percentage Pain Intensity with and without Entonox Pain Intensity

  9. 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)

  10. 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

  11. Strategies to Decrease Complications with CSE • Decrease dose of opioid: • Fentanyl 15-20 µg • Sufentanil 2.5-5 mg • Combine with: • Local anesthetic (bupivacaine 1.25-2.5 mg) • Epinephrine

  12. Controversial Areas • Effects on labor and delivery process • Maternal temperature elevation • Drug choice - are new agents better? • Epidural vs. CSE

  13. LOCAL ANESTHETICS • Continuous infusion: • Bupivacaine 0.0625%-0.25%-8 -15 ml/hr • Ropivacaine: 0.125%-0.25%- 6 -12 ml/hr • Lidocaine: 0.5%-1% -8-15 ml/hr • 2-chloroprocaine 0.75% -27 ml/hr • Intermittent bolus injections: • Bupivacaine: 0.125%-0.375%, 5-10 ml, duration:1-2 hr • Ropivacaine: 0.125%-0.25%, 5-10 ml, duration: 1-2 hr • Lidocaine: 0.75%-1.5%, 5-10 ml, duration: 1-1.5 hr • 2 chloroprocaine 1-2%, 5-10 ml, duration: 0.75-1 hr

  14. EPIDURAL ANALGESIA Disadvantages: Not instant in onset May be associated with motor block Postdural puncture headache (50-85% with 16 or 18-G Tuohy’s needle)

  15. LEVEL OF BLOCK High Level: Can result from high dose or subdural/subarachnoid migration of catheter Low level: Can result from intravenous migration of catheter, catheter outside the epidural space or administration of inadequate dose of local anesthetic

  16. CONTINUOUS EPIDURAL INFUSION • Still used routinely at many centers • Good pain relief • Less motor block • Maternal and neonatal drug concentrations safe if used cautiously • We routinely use either • 0.0625% bupivacaine+fentanyl 2.5 μg/ ml at 12 ml/hr (early labor)+demand dose: 4 ml q 15 min • 0.125% bupivacaine+fentanyl 2 μg/ml at 8 ml/hr (advanced labor)+ demand dose : 3 ml q 15 min

  17. PATIENT CONTROLLED EPIDURAL ANALGESIA Advantages: Flexibility and benefit of self administration Ability to minimize drug dosage Reduced demand on professional time Disadvantages: May provide uneven block Addition of a basal infusion provides: More even block producing greater patient satisfaction

  18. Are We Doing Enough? • Facemasks • Prep solution (Betadine) • Gloves • Bacterial Filter • Filtered Needle

  19. Hand Care • Washing with alcohol based solution • Artificial nails • Gram-negative pathogens on their fingertips • Jewelry • Areas under rings more heavily colonized that comparable areas

  20. Conclusions • Individualize technique to patient’s goals and stage of labor • Optimize management for spontaneous delivery • Provide safe, cost-effective analgesia

  21. Point

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