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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.

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Anesthesia for Episiotomy and Perineal Laceration
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

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

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Anesthesia for Forceps Delivery
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 aggressively
Caudal epiduralAlmost never used ...

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