Regional analgesia and anaesthesia in obstetrics

  • C. Benedetti
  • M. Mercieri
Part of the Topics in Anaesthesia and Critical Care book series (TIACC)


Bonica, in the mid-forties, realized the importance of providing safe analgesia and anaesthesia for parturients. In 1947, he developed the first obstetrical anaesthesia service in the world to provide continuous analgesia and anaesthesia care to these patients [1]. The need of proper pain control during parturition, which John Bonica perceived through his clinical observation and acumen, was confirmed several decades later by the research of Melzack. In 1994, Melzack published a study which demonstrated that, in the majority of women, the pain associated with parturition is more intense than neoplastic pain and pain secondary to a bone fracture [2]. This paper also brought to the forefront a concept seldom understood by most physicians. The assessment of the intensity of pain is often overlooked by clinicians and until they realize the enormous difference existing between tolerable and intolerable pain as rated by each individual patient, pain will continue to be inappropriately treated. For instance, when we speak of labor analgesia the aim is not to produce a completely pain-free parturition, but to reduce the pain to an acceptable level. A proper level of analgesia will allow the mother to actively participate in the labor while being spared the atrocity of uncontrolled, intolerable pain.


Caesarean Section Epidural Analgesia Epidural Catheter Cerebral Spinal Fluid Spinal Needle 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Benedetti C, Chapman CR, Bomca JJ (1990) A life dedicated to the alleviation of human suffering. In: Benedetti C, Chapman CR, Giron G (eds) Opioid analgesia recent advances in systemic administration. Advances in Pain Research and Therapy. Raven Press, New York, pp 16–17Google Scholar
  2. 2.
    Melzack R (1984) The myth of painless childbirth. Pain 19: 321–337PubMedCrossRefGoogle Scholar
  3. 3.
    Wagner A, Grenom A, Pierre F, Soutoul JH, Fabre-Nys C, Krebhiel D (1989) Maternal behaviour toward her newborn infant Potential modification by pendural analgesia or childbirth preparation. Rev Fr Gynecol Obstetr 84: 29–35Google Scholar
  4. 4.
    Bomca JJ (1980) Obstetric analgesia and anaesthesia. World Federation of Societies of Anaesthesiologists, AmsterdamGoogle Scholar
  5. 5.
    Thorp JA, Hu DH, Albin RM, McNitt J, Meyer BA, Cohen GR, Yeast JD (1993) The effect of intrapartum epidural analgesia on nulliparous labor. a randomized, controlled prospective trial. Am J Obstet Gynecol 169: 851–858PubMedGoogle Scholar
  6. 6.
    Chestnut DH, McGrath JM, Vincent RD et al (1994) Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are in spontaneous labor. Anaesthesiology 80: 1201–1208CrossRefGoogle Scholar
  7. 7.
    Raabe N, Belfrage P (1976) Lumbar epidural analgesia in labour. A clinical analysis Acta Obstet Gynecol Scand 55: 125–129CrossRefGoogle Scholar
  8. 8.
    Hall WL (1977) Epidural analgesia and its effect on the normal progress of labor. Am J Obstet Gynecol 129: 316Google Scholar
  9. 9.
    Crawford JS (1972) The second thousand epidural blocks in an obstetric hospital practice. Br J Anaesth 44: 1277PubMedCrossRefGoogle Scholar
  10. 10.
    Crawford JS (1972) Lumbar epidural block in labor a clinical analysis. Br J Anaesth 44: 66PubMedCrossRefGoogle Scholar
  11. 11.
    Maresh M et al (1983) Delayed pushing with lumbar epidural analgesia in labour Br J Obstet Gynecol 90: 623Google Scholar
  12. 12.
    Benedetti C, Tiengo M (1990) Continuous subarachnoid analgesia in labour Lancet 335–225Google Scholar
  13. 13.
    Morton CP, Armstrong PJ, McClure JH (1993) Continuous subarachnoid infusion of local anaesthetic. Anaesthesia 48: 333–336PubMedCrossRefGoogle Scholar
  14. 14.
    Rawal N (1995) European trends in the use of combined spinal epidural technique - a 17 nation survey. Reg Anaesth 20: 162Google Scholar
  15. 15.
    Rawal N, Van Zundert A, Holmstrom B, Crowhurst JA (1997) Combined spinal-epidural technique. Reg Anaesth 22: 406–423CrossRefGoogle Scholar
  16. 16.
    Collis RE, Baxandall ML, Srikantharalah ID, Edge G, Kadim MY, Morgan BM (1993) Combined spinal epidural analgesia with ability to walk throughout labour. Lancet 341: 767–768PubMedCrossRefGoogle Scholar
  17. 17.
    Nageotte MP, Larson D, Rumney PJ, Sidhu M, Hollenbach K (1997) Epidural analgesia compared with combined spinal-epidural analgesia during labor in nulliparous women. N Engl J Med 337: 1715–1719PubMedCrossRefGoogle Scholar
  18. 18.
    Katz N, Hurley R (1993) Epidural anaesthesia complicated by fluid collection within the spinal cord. Anaesth Analg 77: 1064–1065CrossRefGoogle Scholar
  19. 19.
    Levin A, Segal S, Datta S (1998) Does combined spinal-epidural analgesia alter the incidence of paresthesia during epidural catheter placement? Anaesth Analg 86: 445–446Google Scholar
  20. 20.
    Brownndge P (1981) Epidural and subarachnoid analgesia for elective Caesarean section. Anaesthesia 36. 70CrossRefGoogle Scholar
  21. 21.
    Holmstrom B, Rawal N, Axelsson K, Nydahl PA (1995) Risk of catheter migration during combined spinal epidural block-percutaneous epiduroscopy study. Anaesth Analg 80: 747–753Google Scholar
  22. 22.
    Joshi G, McCaroll S (1994) Evaluation of combined spinal-epidural anaesthesia using two different techniques. Reg Anaesth 19: 169–174Google Scholar
  23. 23.
    Reynolds F, Speedy H (1990) The subdural space: the third place to go astray. Anaesthesia 45. 120–123PubMedCrossRefGoogle Scholar
  24. 24.
    Carter LC, Popat MT, Wallace DH (1992) Epidural needle rotation and inadvertent dur-al puncture with catheter. Anaesthesia 47: 447–448PubMedCrossRefGoogle Scholar
  25. 25.
    Lyons G, MacDonald R, Mikl B (1992) Combined epidural spinal anaesthesia for Cae- sarean section. Through the needle or in separate spaces? Anaesthesia 47: 199–201PubMedCrossRefGoogle Scholar
  26. 26.
    Lyons G (1995) Epidural is an outmoded form of regional anaesthesia for elective. Caesarean section. Int J Obst Anaesth 4: 34–39CrossRefGoogle Scholar
  27. 27.
    Cesarini M, Torrielli R, Lahaye F, Mene JM, Cabiro C (1990) Sprotte needle for intrathecal anaesthesia for Caesarean section: incidence of post-dural puncture headache. Anaesthesia 45: 656–658PubMedCrossRefGoogle Scholar
  28. 28.
    Ross BK, Chadwick HS, Mancuso JJ, Benedetti C (1992) Sprotte needle for obstetric anaesthesia: decreased incidence of post durai puncture headache. Reg Anaesth 17: 29–33Google Scholar
  29. 29.
    Sears DH, Leeman MI, O’Donnell RH et al (1990) Incidence of postdural puncture headache in Caesarean section patients using the 24 G Sprotte needle. Anesthesiology 73: A1003CrossRefGoogle Scholar
  30. 30.
    Cox M, Lawton G, Gowrie-Mohan S, Priest T, Arnold A, Morgan BM (1995) Ambulatory extradural analgesia. Br J Anaesth 74: 114CrossRefGoogle Scholar
  31. 31.
    Brownridge P (1991) Spinal anaesthesia in obstetrics. Br J Anaesth 67: 663PubMedCrossRefGoogle Scholar
  32. 32.
    Dennison B (1987) Combined subarachnoid and epidural block for Caesarean section. Can Anaesth Soc J 34: 105–106CrossRefGoogle Scholar
  33. 33.
    Abboud T, Zhu J, Reyes A, Miller H, Steffens Z, Afrasiabi K, Afrasiabi A, Sherman G, Emershad B (1992) Effect of subarachnoid morphine on the incidence of spinal headache. Reg Anaesth 17: 34–36Google Scholar
  34. 34.
    Eldor J, Guedj P, Cotev S (1990) Epidural morphine injections for the treatment of postspinal headache. Can J Anaesth 37: 710–711PubMedCrossRefGoogle Scholar
  35. 35.
    Norris MC, Grieco WM, Borkowski M, Leighton BL, Arkoosh VA, Huffnagle HJ, Huff-nagle S (1994) Complications of labor analgesia: epidural versus combined spinal epidural techniques. Anaesth Analg 79: 529–537CrossRefGoogle Scholar
  36. 36.
    Camann WR, Mrnzter BH, Denney RA, Datta S (1993) Intrathecal sufentanil for labor analgesia. Effects of added epinephrine. Anaesthesiology 78: 870–874Google Scholar
  37. 37.
    Van Decar T, Callicot R, Jones R, Herman MD (1994) Determination of a dose response curve for intrathecal sufentanil in labor. Anesthesiology 81: A1148CrossRefGoogle Scholar
  38. 38.
    Gautier PE, Debry F, Fanard L, Van Steenberge A, Hody JL (1997) Ambulatory combined spinal epidural analgesia for labor. Influence of epinephrine on bupivacaine-sufentanil combination. Reg Anaesth 22: 143–149Google Scholar
  39. 39.
    Yaksh T, Reddy SVR (1981) Studies in the primate on the analgesic effects associated with intrathecal action of opiates, alpha-adrenergic agonists and baclofen. Anaesthesiology 54: 451–467CrossRefGoogle Scholar
  40. 40.
    Ossipov MH, Suarez IJ, Spaulding TC (1989) Antmociceptive interactions between alpha-2 adrenergic and opiate agonists at the spinal level in rodents. Anesth Analg 68: 194–200PubMedCrossRefGoogle Scholar
  41. 41.
    Segal S, Eappen S, Datta S (1997) Superiority of multi-orifice over single-orifice epidur- catheters for labor analgesia and Caesarean delivery J Clin Anaesth 9:109–112Google Scholar
  42. 42.
    Robin SH, Hew E, Ogilvie G (1987) A comparison of two types of epidural catheters. Can J Anaesth 34: 459–461CrossRefGoogle Scholar
  43. 43.
    Kartawladi SL, Vercauteren MP, Van Steenberge AL, Adriaensen HA (1996) Spinal analgesia during labor with low-dose bupivacaine, sufentanil, and epinephrine. A comparison with epidural analgesia. Reg Anaesth 21.191–196Google Scholar
  44. 44.
    Rawal N (1986) Single segment combined spinal epidural block for Caesarean section. Can Anaesth Soc J 33. 254–255PubMedCrossRefGoogle Scholar
  45. 45.
    Rawal N, Schollm J, Wesstrom G (1988) Epidural versus combined spinal epidural block for Caesarean section. Acta Anaesthesiol Scand 32 61–66PubMedCrossRefGoogle Scholar
  46. 46.
    Thoren T, Holmstrom B, Rawal N, Schollin J, Lindeberg S, Skeppner G (1994) Sequential combined spinal epidural block versus spinal block for Caesarean section• effects on maternal hypotension and neurobehavioral function of the newborn. Anaesth Analg78. 1087–1092Google Scholar
  47. 47.
    Swami A, McHale S, Abbott P, Morgan B (1993) Low dose spinal anaesthesia for Caesarean section using combined spinal-epidural ( CSE) technique. ( Abstract) Anaesth Analg 76: S423Google Scholar
  48. 48.
    Fan S-Z, Susetio L, Wang Y-P, Liu CC (1994) Low dose of intrathecal hyperbaric bupivacame combined with epidural hdocaine for Caesarean section — a balance block technique. Anaesth Analg 78: 474–477CrossRefGoogle Scholar
  49. 49.
    Kumar C (1987) Combined subarachnoid and epidural block for Caesarean section. Can J Anaesth 34: 329–330PubMedCrossRefGoogle Scholar
  50. 50.
    Bernards CM, Kopacz DJ, Michel MZ (1994) Effect of needle puncture on morphine and lidocame flux through the spinal meninges of the monkey in vitro. Implications for combined spinal-epidural anaesthesia. Anaesthesiology 80: 853–858Google Scholar
  51. 51.
    Zaric D, Axelsson K, Haligren S, Nydahl P-A, Philipson L, Samuelsson L (1996) Evaluation of epidural sensory motor blockade by thermostimulation, laser stimulation and recording of somatosensory evoked potentials Reg Anaesth 21: 124–130Google Scholar
  52. 52.
    Bromage P (1975) Mechanism of action of extradural anaesthesia. Br J Anaesth 47: 199–212PubMedGoogle Scholar
  53. 53.
    Suzuki N, Koganemaru M, Onizuka S, Takasaki M (1996) Dural puncture with a 26 gauge spinal needle affects spread of epidural anaesthesia. Anaesth Analg 82. 1040–1042Google Scholar
  54. 54.
    Blumgart CH, Ryall D, Dennison B, Thompson-Hill LM (1992) Mechanism of extension of spinal anaesthesia by extradural mlection of local anaesthetic. Br J Anaesth 69: 457–460PubMedCrossRefGoogle Scholar
  55. 55.
    Stemstra R, Dahan A, Alhadi ZRB, van Kleef JW, Burm AGL (1996) Mechanism of action of an epidural top-up in combined spinal epidural anaesthesia. Anaesth Analg 83.382–386Google Scholar
  56. 56.
    Ramsay M (1991) Epidural mlection does cause an increase in CSF pressure. Anaesth Analg 73: 668CrossRefGoogle Scholar
  57. 57.
    Morgan BM (1995) Is an epidural test dose necessary? Eur J Obstet Gynecol 59: 559–560Google Scholar
  58. 58.
    Ong B, Cohen MM, Cumming M, Palahmuk RJ (1987) Obstetrical anaesthesia at Winnipeg Women’s Hospital 1975–83: anaesthetic technique and complications. Can J Anaesth 34294–299PubMedCrossRefGoogle Scholar
  59. 59.
    Ducey JP, Knape KG, Talbot J et al (1992) Intrathecal narcotics for labor cause hypotension Anaesthesiology 77: A997Google Scholar
  60. 60.
    Cohen SE, Cherry CM, Holbrook RH Jr et al (1993) Intrathecal sufentanil for labor analgesia — sensory changes, side effects, and fetal heart rate changes Anaesth Analg 77: 1155–1160Google Scholar
  61. 61.
    Anderson M, D’Angelo R, Philip J et al (1993) Intrathecal sufentanil compared to epidural bupivacame for labor analgesia. Anaesthesiology 79: A970Google Scholar
  62. 62.
    Kirno K, Lundin S, Elam M (1993) Effects of intrathecal morphine and spinal anaesthesia on sympathetic nerve activity in humans. Acta Anaesth Scand 37: 54–59PubMedCrossRefGoogle Scholar
  63. 63.
    Hill JM, Kaufman MP (1990) Attenuation of reflex pressor and ventilatory responses to static muscular contraction by intrathecal opioids. J Appl Physiol 68: 2466–2472PubMedGoogle Scholar
  64. 64.
    Abboud TK, Shnider SM, Dailey PA et al (1984) Intrathecal administration of hyperbaric morphine for the relief of pain labor. Br J Anaesth 56: 1351–1359PubMedCrossRefGoogle Scholar
  65. 65.
    Camann WR, Denney RA, Holby ED, Datta S (1989) A comparison of intrathecal, epidural, and intravenous sufentanil for labor analgesia. Anaesthesiology 77: 884–887CrossRefGoogle Scholar
  66. 66.
    Camann WR, Minzter BH, Denney RA, Datta S (1993) Intrathecal sufentanil for labor analgesia Effects of added epinephrine. Anaesthesiology 78: 870–874CrossRefGoogle Scholar
  67. 67.
    Thomas DA, Williams GM, Iwata K et al (1993) The medullary dorsal horn A site of action of morphine in producing facial scratching in monkeys. Anaesthesiology 79: 548–554CrossRefGoogle Scholar
  68. 68.
    Scott PV, Fischer HB (1982) Intraspinal opiates and itching: a new reflex? Br Med J 284: 1015–1016CrossRefGoogle Scholar
  69. 69.
    Stevens RA, Petty RH, Hill HF et al (1993) Redistribution of sufentanil to cerebrospinal fluid and systemic circulation after epidural administration in dogs. Anaesth Analg 767: 323–327Google Scholar
  70. 70.
    Ferouz F, Norris MC, Arkoosh VA, Leighton BL, Boxer LM, Corba RJ (1997) Baricity, needle direction, and intrathecal sufentanil labor analgesia. Anesthesiology 86: 592–598PubMedCrossRefGoogle Scholar
  71. 71.
    Kileff ME, James FM, Dewan DM, Floyd RB (1984) Neonatal neurobehaviour responses after epidural anaesthesia for caesarean section using lidocaine and bupivacame. Anaesth Analg 63: 413–417CrossRefGoogle Scholar
  72. 72.
    Larsen JV (1982) Obstetric analgesia anaesthesia. Clin Obstet Gynecol 9: 685–709Google Scholar
  73. 73.
    Morgan BM, Aulakh JM, Barker JP, Goroszeniuk T, Trojanowski A (1983) Anaesthesia for Caesarean section — a medical audit of junior anaesthetic staff practice. Br J Anaesth 55: 885–889PubMedCrossRefGoogle Scholar
  74. 74.
    Abboud T, Dror A, Mossad P (1988) Mini-dose intrathecal morphine for relief of post-caesarean section pain. Anaesth Analg 67: 370–374CrossRefGoogle Scholar

Copyright information

© Springer Verlag Italia, Milano 1999

Authors and Affiliations

  • C. Benedetti
  • M. Mercieri

There are no affiliations available

Personalised recommendations