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  • image The most common morbidities encountered in obstetrics are severe hemorrhage and severe preeclampsia.

  • image 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.

  • image 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.

  • image Using a local anesthetic–opioid mixture for lumbar epidural analgesia during labor significantly reduces drug requirements, compared with using either agent alone.

  • image Analgesia during labor requires neural blockade at the T10–L1 sensory level in the first stage of labor and at the T10–S4 sensory level in the second stage.

  • image 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.

  • image Epidural analgesia does not increase the rate of operative delivery and has little, if any, effect on labor progress when dilute mixtures of a local anesthetic and an opioid are used.

  • image Unintentional intravascular or intrathecal placement of an epidural needle or catheter is possible even when needle or catheter aspiration does not yield blood or cerebrospinal fluid.

  • image Hypotension is a common side effect of regional anesthetic techniques and can be treated with intravenous boluses of phenylephrine (40–120 mcg), supplemental oxygen, left uterine displacement, and an intravenous fluid bolus to prevent fetal compromise.

  • image Techniques using combined spinal–epidural (CSE) analgesia and anesthesia may especially benefit patients with severe pain early in labor and those who receive analgesia/anesthesia immediately prior to delivery.

  • image Spinal or epidural anesthesia is preferred to general anesthesia for cesarean section because regional anesthesia is associated with less hemodynamic fluctuation, more gradual resolution of analgesia during anesthetic recovery, and lower maternal mortality.

  • image Continuous epidural anesthesia allows better control over the sensory level than “single-shot” spinal anesthesia. Conversely, spinal anesthesia has a more rapid, predictable onset; may produce a more dense (more complete) block; and lacks the potential for serious systemic drug toxicity because of the smaller dose of local anesthetic employed.

  • image Risk of systemic local anesthetic toxicity during epidural analgesia and anesthesia is minimized by slowly administering dilute solutions for labor pain and by fractionating the total dose administered for cesarean section into 5-mL increments.

  • image Maternal hemorrhage is one of the most common and severe morbidities complicating obstetric anesthesia. Causes for antepartum hemorrhage include placenta previa, abruptio placentae, and uterine rupture. Common causes of postpartum hemorrhage include uterine atony, a retained placenta, obstetric lacerations, uterine inversion, and use of tocolytic agents prior to delivery.

  • image Intrauterine asphyxia during labor is the most common cause of neonatal depression. The benefit of continuous fetal heart rate monitoring throughout labor is controversial, but it is routinely used in combination with other fetal surveillance methods to guide the clinical management of parturients.

This chapter focuses on the practice of ...

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