OBSTETRIC ANESTHESIA

AN OVERVIEW BY DALTON THAMES, CRNA

 ANAWHAAATT???

• ANESTHESIA LITERALLY TRANSLATED MEANS

“WITHOUT SENSATION”
• CRNA – CERTIFIED REGISTERED NURSE
ANESTHETIST/ANESTHESIOLOGIST
• WHAT DO WE DO SPECIFICALLY FOR
MOTHERS GIVING BIRTH?
• WHY DO WE DO THIS?
• WHEN DO WE DO THIS?
• HOW DO WE DO THIS?
• IS ANESTHESIA INVOLVEMENT NECESSARY?
 GOALS
• GIVE BRIEF EXPLANATIONS OF THE FOLLOWING:
• SPINAL ANESTHESIA
• EPIDURAL ANESTHESIA
• COMBINED SPINAL/EPIDURAL ANESTHESIA
• GENERAL ENDOTRACHEAL ANESTHESIA
• COVER IMPORTANT ANATOMY TO BETTER UNDERSTAND EPIDURALS AND
SPINALS
• SHOW/DEMONSTRATE SOME OF THE EQUIPMENT USED IN EPIDURALS AND
SPINALS
• DISCUSS THE DIFFERENCES AND SIMILARITIES OF EPIDURALS AND SPINALS AS
WELL AS THE RISKS INVOLVED AND HOW TO RESPOND TO AVERSE SITUATIONS
• TALK ABOUT THE DREADED “CRASH SECTION” AND EXPLAIN THE ROLE OF
ANESTHESIA IN THIS PROCESS
• ANSWER ANY QUESTIONS!
NEUROANATOMY
NEUROANATOMY
ANATOMY SLIDE
ANATOMY SLIDE
ANATOMY SLIDE
 NERVE BLOCKADE!! YAY!
• SENSATION IS NEVER AN ALL OR NOTHING EVENT WHEN IT COMES TO THE
NERVOUS SYSTEM
• THERE ARE DIFFERENT SIZES AND SHAPES OF NERVES DEPENDING ON THEIR
FUNCTION
• PRIMARY CATEGORIES: ⍺, Β, 𝜸, ẟ, AND C FIBERS

• MYLENATED VERSUS NON MYLENATED, SHORT VERSUS LONG, THICK VERSUS

THIN
• BLOCKADE HAPPENS IN PREDICTABLE STAGES
• SYMPATHETIC TONE, LIGHT TOUCH, COLD, DEEP TOUCH, PIN PRICK, MOTOR,
PROPRIOCEPTION
 EPIDURAL ANESTHESIA WITH CATHETER

• EPIWHAAAAA???
• EPIDURAL – “ABOVE THE DURA”
• CONTINUOUS LABORING EPIDURAL (ANALGESIA) VERSUS EPIDURAL ANESTHESIA
• COMMON QUESTIONS
• WHAT IS IT?
• COULD I BE PARALYZED?!
• WHAT ARE THE RISKS?
• WHAT ARE THE BENEFITS?
 EPIDURAL ANESTHESIA
• INTRODUCTION OF LOCAL ANESTHETIC (WITH OR WITHOUT ADDITIVES) INTO THE
EPIDURAL SPACE USUALLY UTILIZING A CATHETER TO PROVIDE CONTINUOUS AND
SUBSTANTIAL PAIN RELIEF TO PATIENTS IN MATERNAL LABOR OR MOTHERS UNDERGOING
CAESARIAN DELIVERY.
• THE POSTERIOR WALL OF THE DURA AS WELL AS THE POSTERIOR NERVE ROOTS ARE
“BATHED” IN LOCAL ANESTHETIC THAT PROVIDES VARYING DEGREES OF NERVE BLOCKADE
• THE VOLUME OF DRUG GIVEN IS THE MOST IMPORTANT FACTOR IN BLOCK HEIGHT. SIDE TO
SIDE SPREAD CAN SOMETIMES DEPEND ON PATIENT POSITION WHEREAS DRUG TYPE AND
CONCENTRATION DETERMINES THE DENSITY OF THE BLOCK.
• A LESS DENSE BLOCKADE IS ACHIEVED BY THIS METHOD COMPARED TO A SPINAL BUT IS
ABLE TO BE EXTENDED THEORETICALLY AS LONG AS THE EPIDURAL CATHETER CAN
SAFELY REMAIN IN THE PATIENT.
• ABSOLUTE CONTRAINDICATIONS: PATIENT REFUSAL, LOCAL INFECTION, ALLERGY TO
MEDICATIONS PLANNED TO BE ADMINISTERED
TOOLS OF THE TRADE - EPIDURAL

LOSS OF RESISTANCE
 TOOLS OF THE TRADE - EPIDURAL

SINGLE PORT VS. MULTI PORT VS. WIRE REINFORCED CRAWFORD VS. TUHOY
MULTIPORT NEEDLE
 EPIDURAL ANESTHESIA PROCEDURE
• CHECK LABS, FLUID BOLUS (BE CAREFUL!), HAVE THE APPROPRIATE MONITORS IN PLACE WITH
RESUSCITATION EQUIPMENT AVAILABLE, INTERVIEW THE PATIENT, DISCUSS AND CONSENT THE
PATIENT
• ASEPTIC TECHNIQUE IS KEY! FOLLOWED BY PATIENT POSITIONING AND PARTICIPATION
• POSITION THE PATIENT AND FIND THE TARGET! (MIDLINE, L3/4 INTERSPACE, PSIS/TUFFIER’S LINE)
• PREP AND DRAPE WITH MASK ON
• LOCALIZE SKIN
• INSERT NEEDLE THEN REMOVE STYLET
• FIND EPIDURAL SPACE
• LOSS OF RESISTANCE (AIR VERSUS SALINE)
• HANGING DROP

• THREAD EPIDURAL CATHETER

• ASPIRATE AND TEST DOSE (IMPORTANT STEP!!) (GIVE IT A SECOND)
• DRESSING
• BOLUS
• PLACE ON PUMP
 SPINAL ANESTHESIA

• PRIMARILY USED FOR CAESARIAN DELIVERY DUE TO ITS PHARMACODYNAMIC

PROPERTIES
• INTRODUCTION OF LOCAL ANESTHETIC (WITH OR WITHOUT ADDITIVES) INTO
THE INTRATHECAL OR SUBARACHNOID SPACE WITH A SINGLE “SHOT” WHERE
THE DRUG CHOSEN MIXES WITH CEREBROSPINAL FLUID AND “BATHES” THE
CAUDA EQUINA TO PRODUCE A DENSE SENSORY BLOCKADE FOR A
SOMEWHAT PREDICTABLE AMOUNT OF TIME.
• NO CATHETER IS PLACED WITH THIS TECHNIQUE
• DOSE OF MEDICATION , BARACITY(WHAAAA) , PROCEDURE LEVEL, AND
PATIENT POSITION DETERMINE BLOCK HEIGHT
• ABSOLUTE CONTRAINDICATIONS: PATIENT REFUSAL, LOCAL INFECTION,
ALLERGY TO MEDICATIONS PLANNED TO BE ADMINISTERED
TOOLS OF THE TRADE FOR SPINAL
INJECTION
 SPINAL INJECTION PROCEDURE
• CHECK LABS, FLUID BOLUS (BE CAREFUL!), HAVE APPROPRIATE MONITORS
ATTACHED WITH RESUSCITATION EQUIPMENT AVAILABLE, INTERVIEW THE
PATIENT, DISCUSS AND CONSENT THE PATIENT
• ASEPTIC TECHNIQUE IS KEY! FOLLOWED BY PATIENT POSITIONING AND
PARTICIPATION
• POSITION THE PATIENT AND FIND THE TARGET (MIDLINE, L3/4 INTERSPACE,
PSIS/TUFFIER’S LINE)
• PREP AND DRAPE WITH MASK ON (DUH, IT’S A C-SECTION)
• LOCALIZE SKIN
• INSERT INTRODUCER NEEDLE IF YOU CHOOSE TO USE IT
• INSERT SPINAL NEEDLE GRADUALLY DEEPER, PERIODICALLY REMOVING THE
STYLET UNTIL CSF APPEARS
• ATTACH SYRINGE AND GENTLY ASPIRATE TO CONFIRM CSF
• INJECT LOCAL ANESTHETIC AND LAY THE PATIENT DOWN QUICKLY
 COMBINED SPINAL/EPIDURAL

• BEST OF BOTH WORLDS … WITH SOME INCREASED RISK OF

PDPH
• YOU GET PROFOUND BLOCKADE WITH THE OPTION OF
EXTENDING THE BLOCK FOR A LONGER DURATION.
• THIS PROCEDURE TAKES SLIGHTLY LONGER TO PREP FOR AND
PREFORM
• UNABLE TO VERIFY INTRATHECAL CATHETER PLACEMENT WITH
TEST DOSE
• MANY VARIATIONS IN DOSING AND MANAGING THIS TECHNIQUE.
 COMBINED SPINAL/EPIDURAL (CSE)
TECHNIQUE
• CHECK LABS, FLUID BOLUS (BE CAREFUL!), HAVE APPROPRIATE MONITORS ATTACHED
WITH RESUSCITATION EQUIPMENT AVAILABLE, INTERVIEW THE PATIENT, DISCUSS AND
CONSENT THE PATIENT
• ASEPTIC TECHNIQUE IS KEY! FOLLOWED BY PATIENT POSITIONING AND PARTICIPATION
• POSITION THE PATIENT AND FIND THE TARGET (MIDLINE, L3/4 INTERSPACE, PSIS/TUFFIER’S
LINE)
• PREP AND DRAPE WITH MASK ON (DUH, IT’S A C-SECTION)
• LOCALIZE SKIN
• POSITION EPIDURAL NEEDLE IN THE EPIDURAL SPACE
• PLACE SPINAL NEEDLE THROUGH EPIDURAL NEEDLE TO PUNCTURE THE DURA TO OBTAIN
ACCESS TO CSF
• INJECT MEDICATION INTO CSF
• PLACE EPIDURAL CATHETER, ASPIRATE, TEST DOSE, AND EITHER BOLUS THE CATHETER OR
SIMPLY TURN THE PUMP ON
 NEURAXIAL COMPLICATIONS

• SOME PHYSILOGIC EFFECTS OF NEURAXIAL ANESTHESIA

(SPINALS AND EPIDURALS FOR OUR PURPOSES)
SHOULD NOT BE CONFUSED WITH COMPLICATIONS!
• HOWEVER RARE THEY MAY BE, THERE ARE REAL RISKS
AND WE SHOULD BE AWARE HOW THEY ARE DIFFERENT
FROM SIDE EFFECTS.
 NEURAXIAL COMPLICATIONS
• HYPOTENSION AND BRADYCARDIA
• SYMPATHETIC BLOCKADE / CARDIOACCELERATOR (T1-T4) BLOCKADE
• MOST COMMON
• TREATMENT:
• IV/IM VASOPRESSORS (EPHEDRINE OR NEOSYNEPHRINE)
• IV FLUID BOLUS (BE CAREFUL!!)

• POST DURAL PUNCTURE HEADACHE (PDPH)

• ACCIDENTAL OR INTENTIONAL PUNCTURE OF THE DURA WITH SPINAL OR EPIDURAL
PLACEMENT
• HEADACHE PRODUCED BY CEREBROSPINAL FLUID (CSF) LEAKAGE RESULTING ON
TENSION OF THE DURA AND/OR PAINFUL COMPENSATORY VASODILATION (NEITHER HAS
BEEN DEFINITIVELY PROVEN)
• CLASSIC PRESENTATION IS SYMPTOMOLOGY (SEVERE HEADACHE, NAUSEA, NECK PAIN,
TINNITUS, BLURRED VISION, DIPLOPIA, AND SEIZURES) EXAGGERATED BY THE SEATED
POSITION AND RELIEVED BY LAYING SUPINE
• TREATMENT FROM CONSERVATIVE TO AGGRESSIVE:
• CAFFEINE AND VIGOROUS HYDRATION – SPONTANEOUS RESOLUTION IS 85%!
• BLOOD PATCH
 NEURAXIAL COMPLICATIONS
• HIGH SPINAL/EPIDURAL
• CAUSED BY LOCAL ANESTHETIC MOVING TOO SUPERIORLY ALONG/INSIDE THE SPINAL
COLUMN
• CAN MOST SERIOUSLY RESULT IN RESPIRATORY COMPROMISE (LET’S TALK ABOUT THAT –
C3,4,5 AND ACCESSORY MUSCLES), CARDIOVASCULAR COLLAPSE, AND/OR SEIZURE.
• CAN ALSO RESULT IN NAUSEA/ VOMITING SECONDARY TO DIRECT ACTION ON THE
CHEMORECEPTIVE TRIGGER ZONE (NAUSEA CENTER OF THE BRAIN), SUDDEN DROP IN
BLOOD PRESSURE, AND UNOPPOSED PARASYMPATHETIC ACTIVITY (HYPERMOBILITY OF
THE STOMACH).
• TREATMENT:
• SIT THE PATIENT UP WITH SUCTION AVAILABLE
• OXYGEN IF THE PATIENT IS SHORT OF BREATH
• TURN OFF EPIDURAL PUMP
• CLOSELY MONITOR BLOOD PRESSURE AND TREAT ACCORDINGLY
• CALL ANESTHESIA IF THEY ARE NOT PRESENT
 NEURAXIAL COMPLICATIONS
• EPIDURAL HEMATOMA
• CAN RESULT IN PRESSURE ON THE SPINAL CORD AND ROOTS CAUSING ISCHEMIA
• SIGNS AND SYMPTOMS INCLUDE MUCH LONGER THAN EXPECTED DURATION OF BLOCKADE,
RADICULAR BACK PAIN, AND BLADDER DYSFUNCTION.
• DIAGNOSED BY MRI
• RISK FACTORS INCLUDE DIFFICULT OR TRAUMATIC NEEDLE OR CATHETER INSERTION,
COAGULOPATHY, ELDERLY AGE, AND FEMALE GENDER
• NOTIFY AN ANESTHESIA PROVIDER TO EVALUATE
• PARAPLEGIA AND CAUDA EQUINA SYNDROME
• 0.1 PER 10,000 OR 0.001% (LESS THAN THIS IN THE USA)
• HISTORICALLY NOT FROM TRAUMATIC INSTRUMENTATION BUT FROM CAUSTIC INJECTATE
DIRECTLY ONTO THE NERVE ROOTS/CAUDA EQUINA
• INFECTION
• BACTERIAL MENINGITIS AND EPIDURAL ABSCESS ARE RARE BUT SERIOUS AND
POTENTIALLY CATASTROPHIC
• HAND HYGIENE!!!!! PREPPING WITH CHLORHEXIDINE IN ALCOHOL HAS BEEN SHOWN TO BE
MOST EFFECTIVE
• PRACTITIONER SHOULD IDEALLY WEAR A MASK AND PRACTICE STERILE TECHNIQUE
 NEURAXIAL COMPLICATIONS
• BACKACHE
• PERHAPS ONE OF THE MOST FEARED COMPLICATION ASSOCIATED WITH
NEURAXIAL ANESTHESIA
• THERE IS NO ASSOCIATION BETWEEN EPIDURAL ANALGESIA AND NEW-ONSET
BACK PAIN UP TO 6 MONTHS POSTPARTUM. MOREOVER, IN A RANDOMIZED,
CONTROLLED TRIAL COMPARING EPIDURAL VERSUS SYSTEMIC ANALGESIA FOR
PAIN RELIEF DURING LABOR, THE RATES OF POSTPARTUM BACK PAIN WERE
IDENTICAL BETWEEN GROUPS, SUGGESTING THAT THE NEURAXIAL TECHNIQUES
DO NOT PLAY A ROLE IN THE DEVELOPMENT OF BACK PAIN AFTER DELIVERY.
 NEURAXIAL COMPLICATION UNIQUE TO
EPIDURAL CATHETERS
• YOU’RE GOING TO KNOW ABOUT IT!!! LETS TALK ABOUT THE TEST DOSE!
• INTRAVASCULAR CANNULATION OF CATHETER
• LOCAL ANESTHESIA TOXICITY SYNDROME
• CNS EXCITATION PROGRESSES TO GENERALIZED CNS DEPRESSION AND COMA,
LEADING TO RESPIRATORY DEPRESSION AND ARREST. CARDIOVASCULAR
COLLAPSE WILL IMMINENTLY FOLLOW
• TREATMENT
• PREVENTION!!!
• TRACHEAL INTUBATION, INTRALIPIDS, CHEST COMPRESSIONS, BENZODIAZEPINES

• INTRATHECAL CANNULATION OF THE CATHETER

• TOTAL SPINAL IF BOLUS IS GIVEN!!! (LIKE A HIGH SPINAL ON STEROIDS)
• TREATMENT
• PREVENTION!!!
• TRACHEAL INTUBATION, BENZODIAZEPINE, TIME
 NEURAXIAL COMPLICATION UNIQUE TO
EPIDURAL CATHETERS
• SUBDURAL CANNULATION OF THE CATHETER
• CATHETER CANNULATION IN BETWEEN THE TWO OUTERMOST LAYERS OF THE MENINGES
• CHARACTERIZED BY 15-30 MINUTE DELAY OF SYMPTOMS RESEMBLING A HIGH SPINAL.
• TREATMENT IS ON A CASE TO CASE BASES BASED ON SYMPTOMS

• CATHETER COMPLICATIONS
• KNOTTING AND SHEARING
• BE CAREFUL WHEN YOU ARE PULLING THE CATHETER
• IF YOU MEET SUBSTANTIAL RESISTANCE, STOP AND CALL ANESTHESIA
• ALWAYS CHECK TO MAKE SURE THE BLACK CATHETER TIP IS INTACT!
 GENERAL ANESTHESIA FOR CAESARIAN
DELIVERY
• NOT THE INITIAL OR PREFERRED METHOD OF ANESTHESIA (WILL EXPLAIN)
BUT SOMETIMES ABSOLUTELY NECESSARY IN CERTAIN INSTANCES.
• THREE PRIMARY INDICATIONS EXIST THAT WARRANT PREFORMING A
GENERAL ANESTHETIC FOR A CAESARIAN DELIVERY (C-SECTION) OVER
NEURAXIAL ANESTHESIA
• ABSOLUTE CONTRAINDICATIONS EXIST FOR SPINAL OR EPIDURAL ANESTHESIA
• INADEQUATE COVERAGE OF NEURAXIAL ANESTHESIA FOR SURGERY
• TRUE EMERGENCY C-SECTION

• THE PATIENT IS RENDERED UNCONSCIOUS AND ENDOTRACHEAL INTUBATION

IS PREFORMED
• THE PATIENT IS PLACED AT INCREASED RISK FOR THE PROCEDURE BUT THE
BENEFITS OF MATERNAL/FETAL SURVIVABILITY OUTWEIGH THE RISK OF
GENERAL ENDOTRACHEAL ANESTHESIA (GETA)
 THE CRASH C-SECTION
• IT’S AN EXTREMELY FAST/EMERGENCY PACED METHOD OF DELIVERING A BABY
TYPICALLY WITHIN MINUTES OF THE DECISION MADE BY THE PATIENTS OB PHYSICIAN.
• THERE IS NO HESITATION ONCE THE DECISION IS MADE BY THE SURGEON AND STAFF
MUST ACT QUICKLY TO ENSURE THE BEST POSSIBLE OUTCOME FOR THE PATIENT AND
NEONATE
• THE PATIENT IS QUICKLY PLACED ON ESSENTIAL MONITORS AND PREPPED FOR
SURGERY AT THE SAME TIME, INDUCED UNDER GENERAL ANESTHESIA VIA IV DRUGS,
INTUBATED AND IMMEDIATELY OPERATED ON AS SOON AT THE PROVIDER VERIFIES
ENDOTRACHEAL INTUBATION.
• THE NEONATE IS DELIVERED WITHIN MINUTES AND IMMEDIATELY ASSESSED FOR
RESUSCITATION NEED BY THE OB STAFF ALONG WITH RESPIRATORY THERAPY.
ANESTHESIA STAFF IS AVAILABLE TO ASSIST NEONATAL INTUBATION IF NECESSARY.
• THE PATIENT IS CONTINUALLY MONITORED AS WITH EVERY SURGICAL PATIENT,
EMERGED FROM GENERAL ANESTHESIA AND EXTUBATED IF POSSIBLE.
 GENERAL ANESTHESIA RISKS SPECIFIC TO
C-SECTION
• POTENTIAL DIFFICULT AIRWAY
• THE INCIDENCE OF FAILED INTUBATION IN THE OBSTETRIC POPULATION IS AT LEAST
EIGHT TIMES HIGHER COMPARED WITH NONPREGNANT FEMALES.
• AIRWAY EDEMA
• NASAL CAPILLARY ENGORGEMENT (EPISTAXIS)
• DECREASED FUNCTIONAL RESIDUAL CAPACITY(WHAAAAA??)
• INCREASED O2 CONSUMPTION (HYPOXIA)
• WEIGHT GAIN, BREAST ENLARGEMENT BLOCKS THE LARYNGOSCOPE!!!!
• FULL DENTITION

• INCREASED RISK OF ASPIRATION

• PRESSURE FROM THE ABDOMEN UPWARDS
• DECREASED LOWER ESOPHAGEAL SPHINCTER TONE
• DELAYED GASTRIC EMPTYING DURING LABOR
• ALWAYS CONSIDERED A FULL STOMACH
 ODDS AND ENDS – LEFT UTERINE
DISPLACEMENT
• AORTOCAVAL COMPRESSION SYNDROME – CONDITION
CAUSED BY COMPRESSION OF THE GREAT VESSELS
NAMELY THE DECENDING AORTA AND INFERIOR VENA
CAVA
• PRODUCES PROFOUND HYPOTENSION AND
RESULTANT TACHYCARDIA AS A RESULT OF
DECREASED VENOUS RETURN AND INCREASED
AFTERLOAD OF THE HEART
• TREATMENT: ROLL PATIENT TO THE LEFT.
 ODDS AND ENDS - MATERNAL
HEMODYNAMIC CHANGES
• INCREASED CARDIAC OUTPUT BY 50%, STARTS INCREASING AS EARLY AS 5 WEEKS
GESTATION ALL THE WAY THROUGH 2 ND TRIMESTER.
• 25% INCREASE IN HEART RATE
• 25% INCREASE IN STROKE VOLUME
• INCREASED BLOOD VOLUME
• WHY IS THIS IMPORTANT?
• CAN CAUSE CARDIAC ISSUES (VALVULAR STRAIN, AND FLUID OVERLOAD)
• WE HAVE TO WATCH HOW MUCH FLUIDS WE GIVE THE PATIENT
• CAPILLARY ENGORGEMENT = NOSE BLEEDS, EDEMATOUS AIRWAYS, AND LARGER SPINAL VEINS