Skip to Main Content
Home Books The Anesthesia Guide

Chapter 190. Anesthesia for Episiotomy, Perineal Laceration, and Forceps Delivery

Imre Rédai, MD, FRCA

  • Sections
  • Print
  • Get Citation

    Citation

    AMA Citation
    Rédai I. Rédai I Rédai, Imre.Chapter 190. Anesthesia for Episiotomy, Perineal Laceration, and Forceps Delivery. In: Atchabahian A, Gupta R. Atchabahian A, Gupta R Eds. Arthur Atchabahian, and Ruchir Gupta.eds. The Anesthesia Guide New York, NY: McGraw-Hill; 2013. http://accessanesthesiology.mhmedical.com/content.aspx?bookid=572&sectionid=42543782. Accessed February 29, 2020.
    MLA Citation
    Rédai I. Rédai I Rédai, Imre.. "Chapter 190. Anesthesia for Episiotomy, Perineal Laceration, and Forceps Delivery." The Anesthesia Guide Atchabahian A, Gupta R. Atchabahian A, Gupta R Eds. Arthur Atchabahian, and Ruchir Gupta. New York, NY: McGraw-Hill, 2013, http://accessanesthesiology.mhmedical.com/content.aspx?bookid=572&sectionid=42543782.

    Download citation file:

    RIS (Zotero)
    EndNote
    BibTex
    Medlars
    ProCite
    RefWorks
    Reference Manager
    Mendeley
    © Copyright
  • Tools
  • Search Book
  • Clip
Top

Anesthesia for all these procedures can be successfully performed by extension of a working labor epidural. The following summary advises for cases where there is no labor epidural in place (or when it is failing to provide analgesia). The use of a labor epidural is briefly summarized at the end of the chapter.

Favorite Table | Download (.pdf) | Print
Anesthesia for Episiotomy and Perineal Laceration
Procedure/commentsTechnique
Local infiltration
  • 1% lidocaine or 2% chloroprocaine
    • Prior to episiotomy
    • For repair of
      • Episiotomy
      • Small lacerations
  • Pudendal block
    • Complications and caveats:
      • Failure of block
      • Systemic absorption of local anesthetic can be fast
      • Deep hematoma (rare but serious)
      • Deep pelvic abscess, subgluteal abscess
      • Operator injury. Needle is close to palpating finger in vagina
  • Use any of
    • 1% lidocaine or mepivacaine or
    • 0.5% bupivacaine or ropivacaine or 2% chloroprocaine
    • With or without epinephrine 1:200,00
  • Transvaginal approach (see Figure 190-1):
    • Insert finger in vagina and identify the ischial spine and the sacrospinous ligament. Advance needle through vaginal mucosa toward the sacrospinous ligament. Once the needle passes through the ligament (loss of resistance), administer 3–10 mL local anesthetic after careful aspiration. Use a needle guard set at 1–1.5 cm
  • Transperineal approach:
    • Insert finger in vagina and identify the ischial spine and the sacrospinous ligament. Insert needle through the skin between anus and ischial tuberosity and direct slightly inferior and lateral to the ischial spine and the ligament. Administer 3–10 mL local anesthetic after careful aspiration
Spinal anesthesia
  • Saddle block
    • 50–70 mg hyperbaric lidocaine or
    • 7.5–9 mg hyperbaric bupivacaine
    • With 15–15 μg fentanyl in the sitting position
    • Keep patient sitting for 5 min
    • Pros
      • Limited spread of block (minimal lower extremity block) enhances recovery
      • Minimizes sympathectomy
      • Profound, rapid-onset block
    • Cons
      • Concerns about transient radiculopathy with hyperbaric solutions and lithotomy position
      • Uncomfortable to sit on injured part
  • Isobaric spinal anesthetic
    • 7.5–10 mg isobaric bupivacaine or
    • 30–45 mg chloroprocaine
    • Pros
      • Can be done in the lateral decubitus position
      • Lesser incidence of transient radiculopathy
    • Cons
    • Slower onset
      • More pronounced sympathectomy
      • Slower recovery of lower extremity strength
GA If regional anesthesia failed or is contraindicated

Anatomy: pudendal nerve, S2–4 distribution.

Figure 190-1. Pudendal Block, Transvaginal Approach
image
View Full Size|Favorite Figure|Download Slide (.ppt)
image

Reproduced from Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CV. Williams Obstetrics. 23rd ed. Figure 19-2. Available at: www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.

Favorite Table | Download (.pdf) | Print
Anesthesia for Forceps Delivery
MethodManagementComments
Local infiltrationEpisiotomy often performed with forceps deliveryInsufficient analgesia
Supplemental agentsN2O, intravenous remifentanil, alfentanil, fentanyl
  • Moderately effective
  • Easy to use
  • Avoid general anesthesia without airway protection
Spinal anesthesia
  • Usually performed in the lateral decubitus position
  • Relatively small amount of local anesthetic is sufficient (5–7.5 mg isobaric bupivacaine with 15 μg fentanyl)
  • Monitor patient carefully for development of hypotension, fetal bradycardia
  • Treat hypotension ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

This site uses cookies to provide, maintain and improve your experience. MHE Privacy Center Close