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Obstetric Anesthesiology

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Essentials of Regional Anesthesia

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Abstract

Obstetric anesthesiology has evolved over the past century to include an emphasis on regional anesthesia techniques over general anesthetics related to concerns over airway changes associated with pregnancy. In addition, in recent years, there has been a focus on the development of safer medications and newer treatments for systemic local anesthetic toxicity. In this regard, a better understanding of physiological changes of pregnancy has led to improvement in positioning and monitoring techniques in obstetric anesthesia practice. Finally, the utilization of a transverse abdominis plane or TAP block, a peripheral nerve block designed to anesthetize the nerves supplying the anterior abdominal wall, can be an excellent adjuvant for postoperative analgesia after cesarean section. This chapter focuses on clinical practice of anesthesia with emphasis on regional anesthesia techniques, potential complications, and evolving strategies to ensure safety in the management of a pregnant patient at delivery.

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Author information

Authors and Affiliations

  1. Perioperative Services, Pediatric Anesthesia, Department of Anesthesiology, Louisiana State University Health Sciences Center—Shreveport, Shreveport, LA, USA

    Debbie Chandler MD

  2. Division of Obstetric Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA

    Ray Paschall MD, MS

  3. Department of Anesthesiology, Louisiana State University Health Sciences Center—Shreveport, Shreveport, LA, USA

    Leslie Robichaux MD & Elyse M. Cornett PhD

  4. Department of Anesthesia, Tulane University, New Orleans, LA, USA

    Burton Beakley MD

  5. Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, LA, USA

    Alan David Kaye MD, PhD

Authors
  1. Debbie Chandler MD
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  2. Ray Paschall MD, MS
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  3. Leslie Robichaux MD
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  4. Burton Beakley MD
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  5. Elyse M. Cornett PhD
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  6. Alan David Kaye MD, PhD
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Editor information

Editors and Affiliations

  1. Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, Louisiana, USA

    Alan David Kaye

  2. Department of Anesthesiology Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA

    Richard D. Urman

  3. Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, USA

    Nalini Vadivelu

Review Questions

Review Questions

  1. 1.

    A G4P3003 presents for third repeat C/S. BMI is 45, and pt. has comorbidities of gestational DM not requiring insulin. VS are BP 145/90, P 98, and SpO2 is 96% on RA. Hct is 32 and blood glu is 145. Last C/S took 2 h to complete due to adhesions encountered. Best choice for anesthesia?

    1. (a)

      Spinal

    2. (b)

      Combined spinal-epidural

    3. (c)

      Epidural

    4. (d)

      General anesthesia

  2. 2.

    Which of the following is an inappropriate rescue drug for high spinal?

    1. (a)

      Vasopressin 2 U IVP

    2. (b)

      Phenylephrine 200 mcg IVP

    3. (c)

      Midazolam 2 mg

    4. (d)

      Ephedrine 10 mg

  3. 3.

    A parturient presents for VBAC at 37 weeks, now G3P2002 with both prior deliveries by C/S due to CPD. U/S reveals anterior placenta. VS are normal and pt. has no significant medical history except for gestational nausea and backache. Pt. wishes to have natural labor. Which of the following is not true?

    1. (a)

      Pt. is at low risk for abnormal placental implantation.

    2. (b)

      Early neuraxial anesthesia placement is preferred.

    3. (c)

      Pt. needs a type and screen in the blood bank.

    4. (d)

      Pt. is at high risk for abnormal placental implantation.

  4. 4.

    Preeclampsia:

    1. (a)

      Occurs before 20-week gestation.

    2. (b)

      Can occur after delivery.

    3. (c)

      Is a contraindication to neuraxial anesthesia.

    4. (d)

      Has a mild, moderate, and severe form.

  5. 5.

    Spinal block height:

    1. (a)

      Is strongly predicted by pt. height.

    2. (b)

      Is reduced in obese patients.

    3. (c)

      Is best predicted by volume of lumbosacral CSF.

    4. (d)

      Is adequate if a T8 level is achieved for C/S.

  6. 6.

    Pregnancy:

    1. (a)

      Is a hypocoagulable state.

    2. (b)

      Is a hypercoagulable state.

    3. (c)

      Has higher baseline maternal BP to feed the fetus.

    4. (d)

      Offers no challenges to the anesthesia provider.

  7. 7.

    Neuraxial anesthesia:

    1. (a)

      Slows labor.

    2. (b)

      Increases the risk for C/S.

    3. (c)

      Causes maternal backache postpartum.

    4. (d)

      Decreases maternal stress catecholamine levels.

  8. 8.

    Urgent C/S will be performed most frequently:

    1. (a)

      For a VBAC patient

    2. (b)

      Fetal heart tracing abnormalities

    3. (c)

      Placental abruption

    4. (d)

      Eclampsia

  9. 9.

    Spinal headache after wet tap:

    1. (a)

      Occurs immediately.

    2. (b)

      Is rarely severe.

    3. (c)

      Is exacerbated by lying down.

    4. (d)

      The definitive treatment is blood patch.

  10. 10.

    Magnesium sulfate therapy:

    1. (a)

      Is a relative contraindication to neuraxial anesthesia.

    2. (b)

      Potentiates neuromuscular blockade.

    3. (c)

      Is algolic.

    4. (d)

      Requires higher dosing of local anesthesia to achieve labor analgesia.

  11. 11.

    Paracervical blocks:

    1. (a)

      Are easier and safer to perform than neuraxial anesthesia.

    2. (b)

      Are safer for the fetus.

    3. (c)

      Are limited to first stage of labor relief.

    4. (d)

      Are limited to second stage of labor relief.

  12. 12.

    Combined spinal-epidural anesthesia:

    1. (a)

      Has been associated with shorter labors.

    2. (b)

      Doubles the risk for postpartum headache.

    3. (c)

      Should only be performed when a parturient wants a walking epidural.

    4. (d)

      Causes profound hypotension.

  13. 13.

    A patient is seen the day after a prolonged vaginal delivery with epidural analgesia. She complains of numbness only in the lateral femoral cutaneous nerve distribution. Which of the following is true?

    1. (a)

      The epidural could not have caused this because it is only a sensory nerve.

    2. (b)

      The effect is probably permanent if it does not resolve within 2 weeks.

    3. (c)

      The obstetric team probably caused it by compressing the nerve under her inguinal ligament during delivery.

    4. (d)

      No follow-up is necessary.

  14. 14.

    Pt. with epidural catheter now s/p SVD with partial abruption but continues to ooze despite 30 U of oxytocin. History of gestational PIH but not preeclamptic.

    1. (a)

      Administer methergine

    2. (b)

      Draw DIC labs

    3. (c)

      Order trauma blood from the blood bank

    4. (d)

      Administer 10 more units of oxytocin

  15. 15.

    The most likely complication for neuraxial anesthesia is:

    1. (a)

      Wet tap

    2. (b)

      Transient neural injury

    3. (c)

      Inadequate analgesia or failed block

    4. (d)

      Infection

Answers

  1. 1.

    The answer is c because the expected duration could exceed single-shot spinal dosing and an epidural is not proven to work in the CSE technique since it cannot be tested after spinal dosing. General anesthesia is least desirable

  2. 2.

    c

  3. 3.

    The answer is a. Pt. has 24–40% chance for accreta and therefore large-volume blood loss

  4. 4.

    The answer is b. As noted, it is in the differential diagnosis for postpartum hypertensive headache

  5. 5.

    c

  6. 6.

    b

  7. 7.

    d

  8. 8.

    b

  9. 9.

    d

  10. 10.

    b

  11. 11.

    c

  12. 12.

    a

  13. 13.

    c

  14. 14.

    The answer is b because that is the probable cause for continued bleeding. Trauma blood is inappropriate without Blood Bank current cross match due to the possibility of changed profile associated with fetal-maternal blood mixing with abruption. Methergine is contraindicated with hypertensive disease of pregnancy

  15. 15.

    c

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Chandler, D., Paschall, R., Robichaux, L., Beakley, B., Cornett, E.M., Kaye, A.D. (2018). Obstetric Anesthesiology. In: Kaye, A., Urman, R., Vadivelu, N. (eds) Essentials of Regional Anesthesia. Springer, Cham. https://doi.org/10.1007/978-3-319-74838-2_21

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  • DOI: https://doi.org/10.1007/978-3-319-74838-2_21

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