obstetric analgesia and anesthesia journal
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Obstetric Analgesia and Anesthesia
Gilbert J. Grant
The first modern recorded use of pain relief for childbirth was in 1847, when Dr. James Young
Simpson administered ether to facilitate vaginal delivery for a woman with a deformed pelvis.
Since that time, obstetric anesthesia practice has evolved from the use of systemic routes for
analgesic administration (inhalation, intravenous, intramuscular) to regional administration of
analgesics by the epidural and spinal routes. Currently, in the USA, more than 60% of parturients
receive regional analgesia to manage their pain of childbirth. An advantage of the regional
approach is that relatively low doses of analgesics reliably provide pain relief. Thus, the fetus is
spared exposure to the relatively large doses of medication required when the systemic approach
is used. Although the systemic route remains an option, it is currently used for a minority of
parturients. This review describes current practices in obstetric anesthesia.
Labor and Vaginal Delivery
Consequences of unrelieved pain
The pain of childbirth, which is likely to be the most severe pain that a woman experiences [1],
results in untoward physiologic effects [2]. The hyperventilation that accompanies labor pain
causes profound hypocarbia, which may suppress the ventilator drive between contractions and
produce maternal hypoxemia and loss of consciousness [3]. The accompanying respiratory
alkalosis interferes with fetal oxygenation by shifting the oxyhemoglobin dissociation curve in
favor of the mother and by producing uteroplacental vasoconstriction [4]. The neurohormonal
responses to stress and pain also conspire to adversely affect placental perfusion and fetal
oxygenation. These changes are mediated by increases in circulating catecholamines, which
decrease uterine blood flow [5]. Epidural analgesia lowers circulating maternal epinephrine, and
effectively inhibits the respiratory [6] and neurohormonal [7] responses to pain, with a resultant
increase in oxygen tension in the parturient and fetus[8]. There is also evidence that unrelieved
pain during childbirth may contribute to the development of postpartum psychologic problems
including postpartum depression [9] and post traumatic stress disorder (PTSD) [10].
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Multimodal Regional Analgesia
Current methods for providing pain relief for labor and vaginal delivery are considerably
different from techniques that were used as recently as 15 years ago. Regional analgesia for
childbirth has been transformed from a one-drug approach using a local anesthetic, to an
approach in which different classes of analgesics are administered concurrently; most commonly,
a local anesthetic and an opioid. Although local anesthetics produce profound analgesia, they
indiscriminately block conduction in all nerves with which they come in contact, and therefore
also produce unwanted effects: hypotension and motor block. Hypotension may decrease fetal
oxygen delivery by reducing placental perfusions. Motor block may cause profound lower
extremity weakness, which can be very distressing for the parturient. Moreover, profound motor
and sensory block may interfere with effective pushing during the second stage, particularly if
the parturient is unable to perceive rectal or vaginal pressure, as the presence of this pressure
facilitates expulsive efforts.
The traditional approach to regional analgesia, in which a local anesthetic was used as the sole
agent, changed when clinicians recognized the analgesic efficacy of opioids administered into
the neuraxis. Unlike local anesthetics, which act by blocking nerve conduction, opioids injected
into the neuraxis inhibit pain by binding to specific spinal opioid receptors. Opioids and local
anesthetics act synergistically, so relatively low doses of each agent are required. This synergism
is the rationale for the concurrent use of a combination of different types of analgesics, and is
known as multimodal analgesia [11]. Some clinicians combine other classes of analgesics such
as those that stimulate adrenergic (e.g, epinephrine, clonidine) and cholinergic (e.g neostigmine)
receptors to further potentiate analgesia.
A distinct advantage of multimodal analgesia is that it produces fewers side effects than typically
occur when a local anasthetic is used alone. The difference causes of analgesics act through
different mechanism, and they also have distinct side effect profiles. Furthermore, the likelihoodof side effect is reduced because with the multimodal approach a relatively low dose of each
component is used. The profound motor block that was a frequent accompaniment of high
concentrations ofnlocal anesthetic does not occur with the low concentrations of local anasthetics
that are part of the multimodal approach. Hypotension, which commonly occured with epidural
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administration of high concentration of local anasthetic, is also less likely to occur when low
concentrations are administered.
Prutoyus and nausea are the most common untoward effects that occur with neuraxial
multimodal analgesics regimens, and are caused by the opioid component. These side - effects
may be dose-related, and are more likely to occur with the relatively water-soluble opioid
morphine, and less likely to occur with the relatively lipopphilic opioid such as fentanyl and
sufentanil. Opioid side effect may be treated by intravenous administration of specific opioid
receptor antagonist such as naloxone,naltrexone, nalmefene, or nalbuphine. Fortunately low
doses of opioid antagonist selectively reverse the unwanted effects without appreciably affecting
the analgesia. Another side effects that may occur after intratechal injection of opioid alone is
fetal bradycardia or late decelerations of the fetal heart rate, as the result of uterine hyperactivity.
This effect is twice as likely To occur after intratechal administration of opioid alone than after
epidural administration of local anasthetic and opioid (24% vs 11%) [12]. The fetal bradycardia
may be reversed by administration of tocolytic, such as terbutaline or nitroglycerine.
For patients, the improved lower extremity mobility is perhaps the most noticable effects of
multimodal analgesia. Although commonly described as a "walking epidural", this term is a
poor descriptor, as few parturients walk much during labor after their pain is relieved.
Furthermore, the lack of motor block is not a result of the epidural approach per se, but may also
be achieved with a spinal approach, or a combined spinal and epidural (combined spinal-
epidural, CSE) approach. The primary determinant of motor block intensity is the concentration
of local anasthetic, not its site of administration.
Epidural, spinal, and combined spinal - Epidural analgesia
Safe and effective multimodal regional analgesia may be achieved by using the epidural or spinalroutes, or a combination of both. An advantage of the epidural approach is that a catheter may be
inserted into the epidural space to facilitate continuous and/or intermitten analgesic dosing to
prolong the duration of pain relief. With spinal techniques, the durationof analgesia is limited
into the duration of action of a single dose, as catheterization of the intrathecal space is rarely
performed. The onset of analgesia is more rapid with the spinal approach (3-5 minutes) than it is
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with the epidural approach (approximately 10 minutes). The CSE approach offers the advantages
of both spinal and epidural techniques; rapid onset of analgesia and prolonged duration if
needed.
The type of regional analgesia chosen for a particular patient depends on many factors. One of
the most important determinants is the anticipated duration of labor. In early labor, when
delivery is not expected for many hours, catheterization of the epidural space is indicated
(epidural or CSE techniques) to establish a conduit for administering multiple doses of
analgesics. For an epidural technique, the analgesic medication is typically administered using a
continuous infusion pump, perhaps with patient- controlled epidural analgesia (PCEA; see
below) for a CsE technique, a dose of analgesics is administered intrathecalky and then a catheter
is inserted into the epidural space. The epidural analgesics may be administered either
immediately after the intrathecal injection,mor when the pain relief from the initial intrathecal
dose begins to wane.
Epidural catheterization is a sensible approach at any time during labor for parturients who have
a high likelihood of an instrumental or operatove delivery, as it permits administrationof
additional anesthetics, should they be needed.if delivery is imminent, a single-shot spinal is a
reasonable choice, because analgesia onset is rapid. However, these patients may benefit more
from a CSE technique, as it requis little additional time compared to an epidural tchnique, and an
indwelling epidural cathetermay be quite helpful. The epidural catheter may be used to
administer additional analgesics if delivery does not occur as quickly as anticipated, if the
intrathecal medication does not produce adequate analgesia, or if an instrumental or operative
delivery is required.
Patient-conolled epidural analgesia
Programmable, microprocessor-controlled infusion pumps facilitate pcise administration of
analgesics into the epidural space. Continuous infusn of analgesics is advantegeous, as it avoids
the peaks and valleys of pain and relief that occur with intermitten bolus dosing. PCEA is a
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further refinement of this tchnology. Originally introduced for intravenous use, PCEA enables
the parturient to "fine-tune" her pain relief. PCEA may be administered using intermitten boluses
exclusevely, or intermitt en boluses superimposed on a backgroundinfusion, which appears to be
a superior strategy[13]. PCEA has many advantages over non PCEA techniques including better
analgesia and decreased anesthetic requirement, as well as improved patient satisfaction [14],
because the patient feels empowered by having some control over her pain relief.
Ideally, PCEA is used to provide analgesia for the duration of labor and delivery. For some
patients, the low dose delivered from the infusion pump may not be adequate for the late first
stage and second stage of labor, when a somatic pain component is superimposed on the visceral
pain input.
Analgetik dan Anastesi Obstetri
Gilbert J. Grant
Penggunaan penghilang rasa sakit untuk persalinan secara modern tercatat pertama kali padatahun 1847, saat dr. James Young Simpson memasukkan ether untuk memfasilitasi persalinan
per vaginam pada wanita dengan deformitas pelvis. Sejak saat itu, penggunaan anastesi obstetric
telah berkembang dari penggunaan jalur sistemik untuk memasukkan analgetik (inhalasi,
intravena, intramuscular) ke analgetik regional melalui jalur epidural dan spinal. Saat ini, di AS,
lebih dari 60% pasien parturient menerima analgetik regional untuk manajemen sakit saat
persalinan. Suatu keuntungan dari pendekatan regional adalah dosis rendah analgetik dapat
digunakan untuk penghilang rasa sakit. Jadi fetus tidak begitu terekspos dengan dosis
pengobatan yang relative besar seperti yang ditemui pada jalur sistemik. Walaupun jalur sistemik
tetap menjadi pilihan, biasanya digunakan hanya pada sedikit pasien, Review berikut ini
menggambarkan penggunaan penggunaan anastesi obstetrik.
Proses persalinan dan Persalinan per vaginam
Konsekuensi dari nyeri menetap
Rasa sakit pada saat persalinan, yang mungkin merupakan nyeri paling berat yang dialami oleh
perempuan, adalah efek fisiologis. Hiperventilasi yang mengikuti nyeri saat persalinan
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menghasilkan hipokarbia, yang dapat menekan ventilasi antara kontraksi dan menyebabkan
hipoksemia maternal dan kehilangan kesadaran. Alkalosis respiratori penyerta berpengaruh paDa
oksigenasi fetus dengan menggeser kurva disosiasi oksihemoglobin untuk ibu dan menghasilkan
vasokontriksi uteroplasenta. Respon neurohumoral untuk stress dan nyeri juga bergabung dan
mempengaruhi perfusi plasenta dan oksigenasi fetus. Perubahan - perubahan ini dimediasi oleh
peningkatan sirkulasi katekolamin, yang menurunkan aliran darah uterin. Analgetik epidural
menurunkan sirkulasi epinefrin maternal dan secara efektif menghambat respirasi dan respon
neurohumoral terhadapmnyeri, dengan total peningkatan di tekanan oksigen pada ibu parturien
dan fetus. Bukti lain juga menunjukkkan bahwa nyeri kenetapmselama proses kelahiran dapat
berkontribusi ke perkembangan masalah psikologi post partum termasuk depresi post partum dan
post traumatic stress disorder (PTSD).
Analgetik regional multimodal
Metoda terbaru untuk penghilang rasa sakit saat melahirkan dan partus pervaginam sudah
berbeda dengan teknik yang digunakan 15 tahun yang lalu. Analgetik regional untuk persalinan
telah berubah daru penggunaan 1 jenis obat dengan anastrsi lokal ke pendekatan dengan berbagai
tipe analgetik yang berbeda yang dimasukkan secara bersamaan, yang paling umum adalah
penggunaan anestesi lokal dan golongan opioid. Walaupun anestesi lokal mempunyai efek
analgetik yang nyata, namun kerjanya adalah menghambat konduksi pada semua nervus yang
berkontak dengannya tanpa ada perbedaan sehingga juga menimbulkan efek samping seperti
hipotensi dan blok motorik. Hipotensi dapat menurukan penghantaran oksigen fetus dengan
mengurangi perfusi plasenta. Blok motorik dapat menyebaBkan kelemahan ekstremitas bawah
yang nyata dan dapat menjadi penyulit untuk ibu yang akan melahirkan. Selanjutnya blok pada
motorik dan sensorik juga terlibat pada pendorongan yang efektif saat kala II, khususnya jika ibu
inpartu tidak bisa merasakan tekanan rectal atau vaginal. Adanya tekanan - tekanan tersebut
dapat menyebabkan usaha - usaha ekspulsif.
Pendekatan lama terhadap analgetik regional dimana anastesi lokal digunakan sebagai agen
tunggal, berubah saat dokter - dokter menemulan kegunaan analgetik dari opioid yang
dimasukkan ke neuraxis. Berbeda dari anastesi lokal yang bekerja memblok konduksi nervus,
opioid disuntikkan ke neuraxis, menghambat nyeri dengan berikatan ke resptor spesifik spinal
opioid. Opioid dan anastesi lokal bekerja secara sinergis sehingga dibutuhkan dalam dosis
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rendah dari masing - masing agen. Kesinergisan ini rasional untuk penggunaan bersamaan dari
kombinasi beberapa tipe analgetik yang berbeda dan dikenal dengan multimodal analgetik.
Beberapa dokter mengkombinasikan jenis - jenis analgetik lain seperti yang dapat menstimulasi
adrenergik dan reseptor kolinergik untuk analgetik potensial selanjutnya.