Labor is a unique event in the life of every mother. This painful experience can be a pleasant one if we can manage its pain as an anesthesiologist or pain physician. Novelty of painless labor procedures in Iran beside some false beliefs, has caused some difficulties in implementing pain control policies in this era. In recent presentation I tried to explain more about not-uncommon and possible complications of standard pain-killer techniques for professional groups involved in vaginal delivery.

1. DR. REZA AMINNEJAD
Adverse Effects of Neuraxial Analgesia and Anesthesia for Obstetrics
Reza Aminnejad, M.D.
Assistant Prof. of Anesthesiology at Qom University of Medical Sciences
Pain Fellow at Shahid Beheshti University of Medical Sciences

2. DR. REZA AMINNEJAD

3. INTRODUCTION
DR. REZA AMINNEJAD
Neuraxial analgesia and anesthesia (i.e., spinal,
epidural, and combined spinal-epidural) for labor and
delivery are generally very safe.
All interventions are associated with adverse effects.
The practice of obstetric anesthesia has evolved in large
part to minimize such adverse effects.

4. SIDE EFFECTS (The Physiologic Effects of Neuraxial Block or Direct Effects of the Medications used for it)
Hypotension (SBP<100 mmHg or a reduction of >20 percent from baseline)
o It can be reduced by fluid co-loading and prophylactic administration of vasopressors.
oHypotension occurs much less commonly after initiation of low dose neuraxial labor analgesia, with a reported
incidence between zero and approximately 14% (Intravenous fluid loading or prophylactic administration of
ephedrine or phenylephrine are unnecessary)
Pruritus (a common side effect of IT opioids; more likely to occur in pregnant and postpartum
women)
oNalbuphine may be more effective for relief of pruritus than naloxone.
oIntravenous propofol, serotonin antagonists (ondansetron), and glucocorticoids are effective treatment options.
oNaloxone, naltrexone, nalbuphine, and droperidol were effective in the prevention of opioid induced pruritus.
Nausea and vomiting (more common with IT morphine)
oSuspected causes are labor itself, systemic opioids, hypotension, neuraxial opioids (#ondansetron, metoclopramide,
dexamethasone, transdermal scopolamine and naloxone)
DR. REZA AMINNEJAD

5. Urinary retention (due to both IT LA & Opioids)
oPostpartum bladder dysfunction is common in patients who have no anesthesia.
oLow concentration epidural solutions are preferred.
oIn any patient who complains of breakthrough pain during labor analgesia, bladder distention should be
considered and bladder catheterization should be performed as necessary.
Fever (more common with epidural analgesia)
Shivering (a common event, even in the absence of analgesia/anesthesia for labor and
childbirth)
oPatients may be warmed with heated blankets or forced air warming systems.
oFurther treatment with intravenous meperidine (12.5 to 25 mg IV) may be used when necessary.
DR. REZA AMINNEJAD

6. COMPLICATIONS
DR. REZA AMINNEJAD

7. Local Anesthetic Systemic Toxicity (LAST)
oInadvertent injection of high volume of a high
concentration of LA into an epidural vein is
responsible event.
oPregnant patients, especially at term, are at
increased risk for it.
oLAST is uncommon during labor analgesia
because of the low concentration of LA used for
epidural labor analgesia.
DR. REZA AMINNEJAD

8. Inadequate Anesthesia
oThis condition is not common (Less than 12%)
oFailure rate is lower for CSE.
oFailed spinal may be affected by
Patient factors (e.g., obesity, anatomic or postsurgical spine abnormalities)
Skill of the anesthesia clinician
The specific neuraxial technique
Technical factors (e.g., equipment used, depth of catheter insertion)
DR. REZA AMINNEJAD

9. Motor Block (in contrast with ability to push!)
oSome means of minimizing motor block:
Combination regimens
Patient controlled epidural analgesia
Programmed intermittent epidural bolus
DR. REZA AMINNEJAD

10. High Neuraxial Block (Total Spinal Anesthesia)
1 In 4336 Blocks
the leading cause of arrests attributed to
obstetric anesthesia)
Causes:
 Unrecognized and unintentional injection of
medication intended for the epidural space into the
subarachnoid or subdural space (via a
malpositioned catheter or needle),
 Transfer of medication from the epidural space into
the subarachnoid space through a dural rent, or
 An overdose of medication injected into the
subarachnoid space
DR. REZA AMINNEJAD

11. PDPH (<1% Following UDP)
Post dural puncture headache (PDPH; spinal headache or post lumbar puncture headache)
The mechanism of headache after CSF leak is unclear, but appears to involve cerebral
vasodilation and/or traction on intracranial structures.
Young pregnant women with a low body mass index (BMI) are at highest risk.
Most PDPHs will resolve in 7 to 10 days if untreated.
Severe, debilitating PDPHs are generally treated with EBP.
Transnasal sphenopalatine ganglion block (Maybe better than EBP)
oFor whom does not desire a blood patch, or for whom a blood patch is relatively contraindicated
Prophylactic epidural blood patch (after an inadvertent dural puncture;?)
Spinal catheter (?)
DR. REZA AMINNEJAD

12. TECHNICAL RECOMMENDATIONS FOR PDPH PREVENTION
Use pencil point (atraumatic) needles for spinal anesthesia and diagnostic LP.
Don’t use larger conventional needle size.
Insert needle with the bevel parallel to the long axis of the spine (needle
orientation is not a relevant issue when pencil point needles are used).
Reinsertion the stylet before removing the pencil point needles.
Perform spinal anesthesia in lateral decubitus rather than sitting position.
Try to do it at the first shoot!
Use saline instead of air for LOR technique.
Consider prophylactic EBP to decrease the intensity and/or duration of
symptoms.
DR. REZA AMINNEJAD

13. Pneumocephalus (LOR with air instead of NS; An EBP is of no value)
oAcute onset
oSevere headache
oNeurologic signs and symptoms
Spinal epidural hematoma (Less frequent in obstetric patients; Low-dose
techniques for labor analgesia facilitate monitoring of at risk patients)
oBack pain occurs in only 25 percent of cases
oProgressive motor and sensory block
oBowel or bladder dysfunction
oType of anticoagulant used, the dose, and the timing of its administration is important in
anticoagulated patients.
oPerform neuraxial anesthesia in patients with platelet counts 50,000 to 70,000/microL if there is
compelling reason to do so after risk-benefit analysis (SA is better than EA).
oPerform neuraxial techniques for patients with platelet counts below 70,000/microL when the cause is
gestational thrombocytopenia or immune thrombocytopenia (ITP) rather than preeclampsia or HELLP
syndrome.
oAvoid neuraxial techniques in any patient with a platelet count below 50,000/microL.
DR. REZA AMINNEJAD

14. Respiratory depression (IT opioids)
oRisk is increased by prior or concomitant administration of systemic opioids.
oTreat with opioid antagonist (e.g., naloxone) 40 to 80 mcg IV increments, followed by an
infusion at a dose of 1 to 2 mcg/kg/minute
Backache (Localized back pain related to tissue trauma at the
site of a neuraxial procedure ; no correlation between neuraxial
analgesia and long term back ache)
Postpartum neuropathy (Extremely rare; usually have obstetric
etiologies)
Severe infection (Epidural abscess and meningitis are uncommon;
mouth commensals bacteria; Aseptic techniques are highly
recommended)
DR. REZA AMINNEJAD

15. FETAL EFFECTS
Neuraxial analgesia can affect the fetus
directly by placental transfer of local
anesthetic or opioids, or indirectly via
maternal effects (i.e., hypotension or uterine
hypertonus).
oPlacental perfusion (The placental bed is not
autoregulated): epidural LAs have been
shown to improve intervillous blood flow
and to be associated with improved
neonatal acid–base status.
DR. REZA AMINNEJAD

16. Fetal Bradycardia
oThis is a result of hypotension, uterine hyperactivity, or increased uterine tone.
oTransient abnormalities would be relate to a reduction in maternal circulating
epinephrine after rapid onset of analgesia, and loss of epinephrine's beta-
sympathomimetic relaxant effects on the myometrium.
oUsually occurs within the first 15 minutes, and when treated with usual
measures, does not result in fetal acidemia, low Apgar scores, or the need for
cesarean delivery.
oFetal bradycardia is more common after intrathecal opioid administration.
However, the rates of cesarean delivery and instrumental delivery were not
increased, and there was no difference in Apgar scores <7 at 5 minutes.
DR. REZA AMINNEJAD

17. TREATMENT OF FETAL BRADYCARDIA
Discontinue intravenous oxytocin
Place the parturient in the lateral decubitus position to relieve aortocaval
compression
Administer supplemental oxygen
Correct hypotension
Fetal scalp stimulation
For persistent uterine hypertonus or tachysystole, administer tocolytic
medication (e.g., nitroglycerin 60 to 90 mcg intravenously, repeated in two to
three minutes, if necessary, followed by terbutaline 250 mcg subcutaneously if
there is no response to nitroglycerin.
DR. REZA AMINNEJAD

18. EFFECTS ON THE PROGRESS AND OUTCOME OF LABOR
Timing of neuraxial analgesia (have no effect on the rate of cesarean delivery or other
obstetric outcomes)
Cesarean delivery (epidural analgesia did not significantly increase the risk of cesarean
delivery)
Instrumental delivery (using high concentrations of LA may increase the risk of instrumental
delivery; no difference for low concentration epidural LA)
Duration of labor
oFirst stage of labor: shorter labor after early administration of neuraxial analgesia in comparison with systemic
opioid analgesia
oSecond stage of labor: there is an association between epidural analgesia and a longer second stage of labor
(from 6 min up to 6 hrs.; shorter prolongation with dilute solutions)
DR. REZA AMINNEJAD

19. EFFECTS ON BREASTFEEDING (CONTROVERSIAL AND DIFFICULT TO STUDY)
Compared with systemic opioids for labor analgesia, neuraxial techniques result in lower or
negligible fetal opioid levels, and would therefore be expected to interfere less with neonatal
feeding behaviors.
DR. REZA AMINNEJAD

20. EFFECTS ON THE NEONATE
In the absence of maternal hypotension prior to delivery, neuraxial analgesia and anesthesia
do not negatively affect the neonate.
Fetal accumulation, neonatal respiratory depression and reduced neonatal behavioral scores
are rare following prolonged epidural opioid infusion.
Neurobehavioral studies in neonates whose mothers received epidural analgesia or systemic
opioids have shown either no difference or improved scores in neonates of mothers receiving
epidurals.
There is no effects on neonatal outcomes (eg, Apgar scores, umbilical blood gases, neonatal
behavioral tests) with administration of 50 to 100 mcg of epidural fentanyl during initiation of
epidural anesthesia, prior to cord clamp.
The doses of opioid used for intrathecal administration are considerably lower than epidural
doses, and maternal systemic uptake is negligible, such that direct fetal or neonatal effects
are unlikely to occur.
DR. REZA AMINNEJAD

21. ALLERGIC REACTION TO LOCAL ANESTHETIC
Allergic reactions to local anesthetics (LAs) are very rare.
Most allergic reactions are delayed-type, cell mediated reactions (delayed local swelling or
contact dermatitis), which are rarely dangerous.
They occur more commonly with ester LAs (eg, 2-choloroprocaine, tetracaine) than with amide
LAs (e.g., lidocaine, bupivacaine, ropivacaine).
Serious IgE-mediated reactions can also occur, including life-threatening anaphylaxis.
Patients who describe symptoms suggestive of this type of reaction should be referred to an
allergist if possible.
Skin testing and graded challenge can determine which specific drugs the patient can safely
receive.
DR. REZA AMINNEJAD

22. DR. REZA AMINNEJAD

23. DR. REZA AMINNEJAD

24. Remember these few words whenever you come across a mother requesting labor pain relief
L: Life is more beautiful with a smile!
A: Acetaminophen has adverse effects too!
B: Benefits are numerous!
O: Old beliefs belong to the past!
R: Restriction is not always immunity!
DR. REZA AMINNEJAD

25. DR. REZA AMINNEJAD