Regional anaesthesia in obstetrics

Catriona Connolly and John McClure

in Principles and Practice of Regional Anaesthesia

Fourth edition

Published on behalf of Oxford University Press

Published in print November 2012 | ISBN: 9780199586691
Published online November 2012 | e-ISBN: 9780191755507 | DOI:

Series: Oxford Textbooks in Anaesthesia

Regional anaesthesia in obstetrics

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Effective and safe regional anaesthesia in obstetrics requires a sound knowledge of the anatomy of the nervous system and reproductive tract, the physiology of pregnancy, and the pharmacology of local anaesthetic drugs. The anaesthetist learns to apply this knowledge through performing regional techniques under close senior supervision on the labour ward and in the operating theatre. The need to provide trainees with such supervised experience was the justification for introducing specialists in obstetric anaesthesia in the mid 20th century in the UK, largely through the efforts of the Faculty (now Royal College) of Anaesthetists and the Obstetric Anaesthetists Association. It was James ‘Young’ Simpson (Simpson 1848) who originally proposed that ‘local anaesthesia’ might be used as an alternative to general anaesthesia, but this was not realized in obstetrics until 1900 when Kreis (1900) used spinal anaesthesia during operative vaginal delivery. Sacral epidural analgesia (with procaine) was first used during labour by Stoeckel (1909) who also warned of the risk of ‘impairing the force of labour’, but regional analgesia, especially lumbar epidural block, is now widely available, there being several reasons for its popularity. The main alternative methods—parenteral and inhalational—have the potential to produce centrally mediated side effects in both mother (e.g. amnesia for the birth, confusion, disorientation, and nausea) and child. In the neonate, the effect can extend from mild neurobehavioural abnormalities, detectable only by sophisticated testing (Brockhurst et al. 2000), to severe respiratory depression with failure to initiate normal respiration at birth. Regional analgesia offers the possibility of maternal pain relief without clouding of consciousness or neonatal depression and has minimal effect on uterine blood flow or the fetus itself (Halpern et al. 1998). Further, low-dose combinations of local anaesthetic and opioid for epidural analgesia are now commonplace and associated with improved maternal satisfaction, a shorter second stage, and a lower incidence of instrumental delivery than earlier high dose local anaesthetic techniques (Cooper et al. 2010b, Hein et al. 2010, James et al. 1998). Additionally, bladder function is better preserved and allows a lower incidence of catheterization during labour (Wilson et al. 2009). Most elective and emergency operative deliveries are now performed under epidural or spinal anaesthesia, so reducing considerably the number of general anaesthetics required and contributing, almost certainly, to the decline in maternal deaths due to anaesthesia in the UK (Reports 1991–2008). Thus pregnant women now have high expectations of safe, effective pain relief in labour, and regional anaesthesia for operative delivery if it is required. It is crucial that these expectations are realistic so written and verbal information should be available in both the antenatal setting (well before the pain of labour interferes with decision-making) and the labour ward for access in early labour. Patient information leaflets, in many languages, are available free-of-charge from the Obstetric Anaesthetists Association Website ( Complete pain relief cannot be guaranteed so it is imperative that women understand that this is the case and that strategies are in place to deal with partial or complete failure of regional block.

Chapter.  12377 words.  Illustrated.

Subjects: Anaesthetics ; Clinical Skills ; Obstetrics

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