Department of Anaesthesia

University of Cape Town

Lecture 21
Obstetric Anaesthesia

The particular concerns in obstetric anaesthesia including the following:
Physiological changes that occur during pregnancy
Specific pregnancy-related pathological conditions
Two patients mom and foetus
Analgesia for labour
Anaesthesia for operative delivery

Physiological changes during pregnancy
Profound physiological changes occur during pregnancy. The changes to the cardiovascular,
respiratory and gastrointestinal systems are discussed, as these are most relevant to anaesthesia; as
well as the pharmacological changes in terms of drug handling.

Cardiovascular changes
Cardiac output increases by 50 %. During labour, cardiac output increases to a peak
immediately after delivery, by a further 40 %.
Blood pressure drops in the first trimester and returns to normal by term. The diastolic blood
pressure shows a more pronounced drop, especially in the 2
nd
trimester.
Utero-placental blood flow is dependent on maternal blood pressure.
Plasma volume increases by 50 % while red cell mass increases by 3 %, causing a dilutional
anaemia.
A hypercoagulable state exists from early in the first trimester, due to increased levels of factors
I, VII, VIII, IX, X and XII, and decreased levels of antithrombin III. This means that there is an
increased risk of deep vein thrombosis and pulmonary embolus.
Supine hypotensive syndrome The gravid uterus may cause aorto-caval compression from as
early as the 20
th
week of gestation; the cardiac output and therefore uterine blood flow may be
compromised in the supine position. The patient should be tilted 30 degrees, left side down (in
10 % of patients, right tilt is better).

Respiratory changes
Mucosal oedema due to capillary engorgement develops in the upper airways. This may
increase the degree of difficulty with intubation.
Functional residual capacity (FRC) decreases by 20 % due to the pressure of the expanding
abdomen on thoracic contents. When lying supine, small airways collapse during tidal volume
breaths in 50 % of pregnant women at term, causing atelectasis.
Oxygen consumption increases by 60 %, so alveolar ventilation increases, and there is a 30 %
drop in P
a
CO
2
levels.
Pain and anxiety increase hyperventilation.

Gastrointestinal changes
Increased risk of regurgitation and aspiration with a general anaesthetic due to the following
factors:
o Progesterone increases gastrin secretion; this increases the volume of gastric fluid and
decreases the pH from early on in pregnancy. The patient is considered to have a full
stomach from 12 weeks gestation onwards.
o Increased regurgitation occurs because the change in the gastro-oesophageal junction
angle and the increased intra-abdominal pressure cause incompetence of the lower
oesophageal sphincter mechanism.
o Pain, anxiety and opiates during labour, will delay gastric emptying even further.
There is a return to normal by 48 hours post-delivery.

Obstetric anaesthesia

21 - 2
Drug handling
There is increased susceptibility to local anaesthetics and general anaesthetics (progesterone
has a sedative effect).
o Minimum alveolar concentration (MAC) decreases by 25

40 %
o LA dose requirements decrease by 40 %
Pharmacodynamics are altered by decreased albumin levels.
Pseudocholinesterase levels are reduced but the increased blood volume counteracts this so
that normal doses of Suxamethonium should be used.

Analgesia for labour
Uterine pain is carried via nerve roots of T
10

L
1
while vaginal pain during delivery is carried via S
2

S
4

nerve roots. The best analgesic option is regional anaesthesia, either epidural or combined spinal-
epidural. These techniques require expertise to perform, and trained personnel and equipment to
safely monitor. Opiates, combined with anti-emetics, can be given via intravenous infusion in a
patient-controlled analgesia (PCA) pump. This requires patient co-operation as well as personnel and
equipment to monitor continuously. Opiates can be administered intramuscularly to lessen side
effects, but patients should still be monitored for respiratory depression. Opiates cross the placenta
and will affect the neonate. The paediatrician should be informed if opiates have been administered
so the baby can be given Naloxone to reverse the effect. Alternative analgesia options include:
Entonox - Nitrous oxide and Oxygen in a 50

:

50 mix; transcutaneous electrical nerve stimulation
(TENS); massage; relaxation techniques (Lamaze); aromatherapy and warm water baths; however
these techniques provide less consistent analgesia.

Anaesthesia for caesarian section
Choice of anaesthetic is based on urgency of surgery, underlying patient conditions and anaesthetic
skill. Spinal anaesthesia is preferred to avoid the risks of general anaesthesia, which are:
(a) Increased risk of difficult intubation,
(b) More rapid desaturation and hypoxaemia
(c) Increased risk of regurgitation in the pregnant woman
and (d) Effects of the general anaesthetic on the unborn foetus.
Regional aesthesia affords further benefits in terms of allowing the partner to be present, and allowing
the mom to participate in the birth, encouraging early bonding and even breast-feeding.
Pre-operative work-up must be the same for regional or general anaesthesia. The patient should be
starved for elective surgery. During labour patients are encouraged to keep well hydrated with clear
oral fluids such as energy drinks, and should not take any solids in case there is a need for operative
delivery. Investigations include vital signs and a haemoglobin level in otherwise fit and healthy
pregnant women. Further investigation will be indicated by the underlying maternal condition. All
patients should be given antacid prophylaxis whether for general or regional anaesthesia: 30 ml
Sodium citrate within 30 minutes of delivery; and Metoclopramide 10 mg PO 2 hours pre-operatively or
IV within 30 minutes of operation. All patients must also receive prophylactic antibiotics to prevent
wound infection: Cefazolin 1 g IV if <

80 kg, or 2 g if >

80 kg within 30 minutes of skin incision.

Neuraxial anaesthesia
a) Spinal (sub-arachnoid block / intrathecal block)
This is the instillation of local anaesthetic into the subarachnoid space to bathe the nerve roots in
order to provide a sensory and motor block. The uterus is innervated by nerve roots T
10

L
2
.
However, for adequate anaesthesia, a block to thoracic dermatome 4 (T
4
) is required as this is an
intra-abdominal procedure. The level is measured by response to cold (Ethyl chloride spray) or pain.
The spinal should last longer than the duration of surgery (approximately one hour). Thin, pencil-point
needles (e.g. 25 G Whitacre) result in fewer post-dural puncture headaches (PDPH) than cutting or
thicker needles (e.g. 22 G Quincke). The highest incidence of PDPH is in the pregnant population.

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21 - 3
Contraindications to neuraxial anaesthesia are discussed in detail in the regional anaesthesia notes.
However specific pregnancy related issues concerning contra-indication should be emphasised.
There is an increased risk of bleeding due to anticoagulant medication in thrombo-embolic
disease; HELLP syndrome in pre-eclampsia; or a platelet count <

75 x 10
9
, and INR >

1,5.
There may be hypotension due to haemorrhage in placenta praevia or abruption; valvular
heart disease; peripartum cardiomyopthy; and the supine hypotensive syndrome.
Raised intracranial pressure and seizures in eclampsia contraindicate a neuraxial technique.

Preparation: Explain the procedure, options, benefits and risks to the patient. Always prepare for
conversion to general anaesthesia (GA) i.e. check machine, airway equipment and drugs. IV access
(at least 18 G peripheral line with a 20 dropper set) and run Ringers Lactate

/

Plasmalyte 20 ml kg
-1

freely while performing the block. Mix Phenylephrine 10 mg into 200 ml saline = 50 g ml
-1
, and
Ephedrine 50 mg into 10 ml saline = 5 mg ml
-1
and LABEL DRUGS.

Method: The patient should sit with their legs over the edge of the bed with a rounded back. Strict
aseptic technique to prevent meningitis. Clean skin with antiseptic and allow it to evaporate. Find L
3

/

L
4
interspace (at level of iliac crests), or use L
2

/

L
3
interspace (the spinal cord reaches L
1

/

L
2
in adults).
Infiltrate subcutaneously with 3

5 ml Lignocaine 1 % or 2 %. Advance the spinal needle through skin,
subcutaneous fat, supraspinous and interspinous ligaments, ligamentum flavum, dura mater and then
into the subarachnoid space. Cerebro-spinal fluid (CSF), that is clear and not bloody, should run
freely out the needle when the stylet is removed. Inject 2,0 ml Bupivacaine 0,5 % with Dextrose and
Fentanyl 10 g (0,2 ml). Discard all needles into the sharps bin.
Tilt the patient 15

30 left side down with a wedge to prevent aorto-caval compression. Measure the
BP every 1 min and talk to the patient to assess cerebral perfusion. Hypotension can occur very
quickly and needs immediate attention with pre-mixed vasopressors (Ephedrine 5

10 mg or
Phenylephrine 50

100 g boli IV) and fluid. Remember uterine perfusion is directly proportional to
maternal blood pressure. Check the sensory level before surgery begins. Monitor for complications.
After delivery, Oxytocin 2,5 5 iu is given IV slowly, followed by an infusion of 10

20 iu l
-1
fluid.
Choice of IV fluids: Crystalloid is cheap and effective to replace blood loss while the requirement is
less then 3 litres. Colloid is more expensive but remain intravascularly for longer. Blood, fresh frozen
plasma (FFP) and

/

or platelets will be required if there is massive intra- or post- operative bleeding.
Discharge the patient from recovery when she is cardiovascularly stable, not bleeding, and has a
receding sensory level at T
10
(level of umbilicus). She should be advised not to walk until all sensation
returns which may take 2

4 hours. A block that is not receding, or motor block that becomes more
pronounced, is highly suspicious of an epidural haematoma. The patient must have an immediate
MRI scan to allow surgical decompression within 6 hours. After that time, permanent neurological
fallout is likely.

b) Epidural (extra-dural)
This is a time-consuming procedure with a less predictable block than a spinal. Analgesia is required
for a short period and often there are no high-care facilities to monitor epidural infusions, so that
epidural catheters are not placed. There are specific times when epidural is useful for caesarean
sections: if there was an epidural in-situ for labour, and there is time (

20 minutes) to top-up the
epidural for adequate surgical anaesthesia (level of T
4
); and in certain cardiac lesions where gradual
afterload reduction would be beneficial. Combined spinal epidural is also popular in some centres.

General anaesthesia
Because of the risk of regurgitation and aspiration, a rapid sequence induction (RSI) is needed, even
for elective cases. Airway difficulties are more common, especially in eclamptic patients. Always
have the difficult airway equipment nearby and have alternative plans if intubation attempts should fail.
Refer to the difficult airway algorithm and failed intubation drill in the Airway Management notes.
Patients desaturate quickly due to higher Oxygen consumption and reduced FRC. Therefore 3

5
minutes of pre-oxygenation with a tight-fitting mask is mandatory. MAC requirements are lower in
pregnant women. However, there is a higher incidence of awareness in these patients. This is due to
conservative use of volatile agents to counteract hypotension and uterine atony; which may contribute
to significant postpartum haemorrhage. Reducing the agent to less than 1 MAC can help improve
uterine contraction, as will an Oxytocin infusion. Do not forget to tilt the patient until delivery. Avoid
sedative drugs (e.g. long-acting opiates or benzodiazepines) until after the umbilical cord is clamped
to limit effect on the foetus. Oxytocin bolus with or without an infusion will be required.
Obstetric anaesthesia

21 - 4
Specific pregnancy-related conditions
1) HIV
Pregnant women are at risk of sexually transmitted diseases and should be offered anti-retroviral
therapy to reduce mother-to-child transmission. Zidovudine (AZT) and Nevarapine (NVP) are given
before caesarean section and during labour, and caesarean section should be delayed (if possible)
until 4 hours post-NVP to increase effectiveness. Patients who are immune-compromised may have
infections and should be assessed pre-operatively for any complications, and treated accordingly.

2) Diabetes
Insulin does not cross the placenta and the foetus undergoes cell hypertrophy to produce Insulin in
response to its hyperglycaemic environment. This results in macrosomia and an increased rate of
caesarean section, as well as neonatal hypoglycaemia.

3) Pre-eclampsia
Pre-eclampsia may be defined as proteinuric hypertension developing after the 20
th
week of
pregnancy or for the first time in labour or the puerperium. It occurs in approximately 10 % of
pregnancies and most commonly between 33

37 weeks gestation. Oedema is not part of the
definition as it occurs in up to 80 % of normotensive pregnancies. Hypertensive diseases of
pregnancy are the main direct cause of maternal death.

Problems
Hypertension
Fluid balance
Central nervous system irritation
Coagulopathy
Intra-uterine growth retardation (IUGR)

Predisposing factors
Maternal
Primagravida
Previous severe pre-eclampsia
Age less than 20 years or greater than 35 years
Positive family history
Microvascular disease such as migraine, chronic hypertension, diabetes, or collagen vascular
disease

Foetal
Multiple pregnancies
Hydatidiform mole
Placental hydrops

Pathophysiology
The aetiology is uncertain but abnormal trophoblastic implantation occurs. In normal pregnancy, there
is trophoblastic invasion of the spiral arteries that increase 4

6 fold in calibre. In pre-eclampsia, spiral
arteries develop to only 40 % of the expected diameter and some undergo atherosis. The changes of
normal implantation are complete by 22 weeks gestation. Thus the deficient implantation process of
pre-eclampsia must be complete by this time although the patient is asymptomatic. Reduced
placental perfusion may be the origin of the systemic disease, conveyed by blood-borne factors.
Vascular endothelium is the target for these products. Glomeruloendotheliosis (non-inflammatory
swelling) provides evidence of endothelial cell injury. Activation of the coagulation cascade and
increased sensitivity to vasopressors are compatible with abnormal endothelial cell function.

Organ dysfunction results from impaired perfusion and may produce the following signs:
Cardiovascular system
o A raised systemic vascular resistance occurs due to increased sensitivity to normally
circulating pressor substances (Adrenaline, Noradrenaline, angiotensin II, Vasopressin,
thromboxane and reduced prostacyclin levels).
o Circulating atrial natriuretic factor is raised and there is a reduced plasma volume.
o The cardiac output is low or normal.
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21 - 5
Renal system
o Glomeruloendotheliosis results in reduced renal blood flow, reduced glomerular filtration
rate and reduced uric acid clearance, which combined cause fluid retention and oedema.
o Proteinuria may also be present and hypo-albuminaemia may exacerbate the oedema.
Central nervous system
o Hyper-reflexia and clonus are common.
o Visual disturbance may be due to cerebral oedema.
o Convulsions may be due to platelet clots in the microcirculation.
The liver
o Usually only mildly involved.
o In the HELLP syndrome (Haemolysis, Elevated Liver enzymes and Low Platelets),
however, severe hepatic dysfunction may occur with peri-portal haemorrhage and necrosis.
o Hepatic rupture may occur.

Prevention
1) Aspirin: The multi-centre, collaborative low-dose Aspirin study in pregnancy (CLASP) was a
study (9364 women) which examined the use of aspirin to prevent pre-eclampsia and intra-
uterine growth retardation. The only group who derived any benefit (reduction in pre-term
delivery) were those especially at risk of early onset pre-eclampsia severe enough to require
very pre-term delivery. It is difficult to predict these women, but those with a previous history of
early onset pre-eclampsia may be considered for low dose aspirin early in the second trimester.
2) Calcium supplements are currently being evaluated.

Treatment
1) Moderate disease: Admit for observation of blood pressure, reflexes and foetal
cardiotocograph (CTG). There is no evidence that bed rest is beneficial. Urine output must be
monitored and proteinuria excluded regularly. Serum urate levels and platelet count should also
be measured frequently. Maternal and foetal conditions will guide the timing of delivery.
2) Severe pre-eclampsia: Fluid administration (including blood products) must be guided by the
CVP. Anti-hypertensives until delivery - Alpha methyl dopa, Nifedipine. MgSO
4
to prevent
seizures.

Fluid therapy
The patient with pre-eclampsia is intravascularly depleted and oliguric, but is also oedematous. The
CVP should be maintained at 2

5 cmH
2
O using conservative IV doses of crystalloid or colloid
solution 10 ml kg
-1
. A low dose of a loop diuretic (Furosemide) may also be needed.
Fulminating pre-eclampsia is associated with a DIC. The ultimate cure is delivery. In the interim,
supportive therapy with fresh frozen plasma, cryoprecipitate, platelets and blood will be required with
reference to repeated clotting studies. Senior haematological advice should be sought.

Analgesia
Provided there is no contra-indication (coagulopathy; or depressed level of consciousness following
seizures; and raised intracranial pressure), epidural is the method of choice. It should be maintained
throughout the labour so that it may be converted quickly for surgical delivery and hence avoid general
anaesthesia. Hypotension should not be tolerated keep the mean arterial pressure within 25 % of
the baseline. In fact, pre-eclamptics are less likely to develop hypotension with neuraxial anaesthesia
versus normal pregnant patients. Careful fluid administration, under CVP guidance, should prevent
this.

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21 - 6
Notes: