Chapter 43

• The most common morbidities encountered in obstetrics are severe hemorrhage and severe preeclampsia.
• Regardless of the time of last oral intake, all obstetric patients are considered to have a full stomach and to be at risk for pulmonary aspiration.
• Nearly all parenteral opioid analgesics and sedatives readily cross the placenta and can affect the fetus. Regional anesthetic techniques are preferred for management of labor pain.
• Using a local anesthetic–opioid mixture for lumbar epidural analgesia during labor significantly reduces drug requirements, compared with using either agent alone.
• Optimal analgesia for labor requires neural blockade at T10–L1 in the first stage of labor and T10–S4 in the second stage.
• Continuous lumbar epidural analgesia is the most versatile and most commonly employed technique, because it can be used for pain relief for the first stage of labor as well as analgesia/anesthesia for subsequent vaginal delivery or cesarean section, if necessary.
• When dilute mixtures of a local anesthetic and an opioid are used epidural analgesia has little if any effect on the progress of labor.
• Even when aspiration does not yield blood or cerebrospinal fluid, unintentional intravascular or intrathecal placement of an epidural needle or catheter is possible.
• Hypotension is the most common side effect of regional anesthetic techniques and must be treated aggressively with ephedrine and intravenous fluid boluses to prevent fetal compromise.
• Techniques using combined spinal epidural analgesia and anesthesia may particularly benefit patients with severe pain early in labor and those who receive analgesia/anesthesia just prior to delivery.
• Spinal or epidural anesthesia is preferred to general anesthesia for cesarean section because regional anesthesia is associated with lower maternal mortality.
• Spinal anesthesia for cesarean section is easier to perform and results in more rapid and intense neural blockade than epidural anesthesia. Epidural anesthesia allows greater control over sensory level and results in a more gradual fall in arterial blood pressure.
• Systemic, local anesthetic toxicity during epidural anesthesia may be best avoided by slowly administering dilute solutions for labor pain and fractionating the total dose for cesarean section into 5-mL increments.
• In general anesthesia for cesarean section, if endotracheal intubation fails, the life of the mother takes priority over delivery of the fetus.
• Maternal hemorrhage is one of the most common severe morbidities complicating obstetric anesthesia. Causes include placenta previa, abruptio placentae, and uterine rupture.
• Pregnancy-induced hypertension describes one of three syndromes: preeclampsia, eclampsia, and the HELLP syndrome.
• Common causes of postpartum hemorrhage include uterine atony, a retained placenta, obstetric lacerations, uterine inversion, and use of tocolytic agents prior to delivery.
• Intrauterine asphyxia during labor is the most common cause of neonatal depression. Fetal monitoring throughout labor is helpful in identifying which babies may be at risk, detecting fetal distress, and evaluating the effect of acute interventions.

Obstetric anesthesia is a demanding but gratifying subspecialty of anesthesiology. The widespread acceptance and use of regional anesthesia for labor has made obstetric anesthesia a major part of most anesthetic practices. The guidelines of the American College of Obstetricians and ...

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