Handbook of Obstetric Anesthesia (Clinical References)

271 Pages·2001·72.2 MB·English

by  Craig M. Palmer

handbook of
OBSTETRIC
ANESTHESIA
Craig M. Palmer
Professor of Clinical Anesthesiology,
University of Arizona Health Sciences Center,
Tucson, AZ, USA
Robert D'Angelo
Associate Professor of Anesthesiology,
Wake Forest University,
Winston Salem, NC, USA
Michael J. Paech
Consultant Anesthesiologist,
King Edward Memorial Hospital for Women,
Perth, WA, Australia
Palmer, Craig M. Handbook of Obstetric Anesthesia.
Oxford,, GBR: BIOS Scientific Publishers Ltd, 2002. p Hi.
http://site.ebrary.com/lib/ircstodomingo/Doc?id=10006558&ppg=3
© BIOS Scientific Publishers Limited, 2002
First published 2002
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Palmer, Craig M. Handbook of Obstetric Anesthesia.
Oxford,, GBR: BIOS Scientific Publishers Ltd, 2002. p iv.
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Contents
Abbreviations ix
Contributors x
Preface xi
1. Overview of obstetric anesthesia
Craig M. Palmer 1
Introduction 2
A brief history of obstetric anesthesia 2
2. Anatomic and physiologic changes of pregnancy
Laura S. Dean and Robert D'Angelo 7
Introduction 8
Cardiovascular 8
Pulmonary 9
Gastrointestinal 10
Renal 10
Hepatic 12
Gallbladder 12
Glucose metabolism 12
Thyroid 13
Hematologic 13
Neurologic 13
Uterus 13
Skeletal 14
Summary 14
3. Fetal assessment
Craig M. Palmer 15
Introduction 15
Normal fetal growth and development 16
Utero-placental physiology 16
Fetal circulation 17
Prepartum fetal assessment 18
Palmer, Craig M. Handbook of Obstetric Anesthesia.
Oxford,, GBR: BIOS Scientific Publishers Ltd, 2002. p v.
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Contents
Intrapartum fetal heart monitoring 21
In-utero resuscitation 24
4. Neuroanatomy and neuropharmacology
Craig M. Palmer 27
Introduction 28
Neuroanatomy 28
Neuropharmacology 34
Conclusion 39
5. Regional analgesia in obstetrics
Robert D'Angelo and John A. Thomas 41
Introduction 42
Epidural analgesia 42
Combined spinal epidural (CSE) analgesia 55
Continuous spinal analgesia 60
Anesthesia for vaginal delivery 61
Alternative regional anesthetic techniques 62
Improving anesthetic efficiency in obstetrics 63
Epidural analgesia and the progress of labor 65
6. Alternative methods of labor analgesia
Michael J. Paech 69
Introduction 70
Preparation for childbirth pain 71
Specific alternative methods of labor analgesia 72
7. Anesthesia for cesarean section
Michael f. Paech 81
History and indications for cesarean section 82
Trends in anesthetic technique for cesarean section 82
Preparation of the patient for cesarean section 86
Spinal anesthesia for cesarean section 92
Epidural anesthesia for cesarean section 96
Combined spinal-epidural anesthesia (CSEA) 99
Continuous spinal anesthesia 102
Failure of regional anesthesia 103
General anesthesia for cesarean section 105
8. Postoperative analgesia
Craig M. Palmer 115
Introduction 116
Epidural morphine 116
Other epidural opioids 119
Nonopioid analgesics 120
Summary of epidural analgesics 121
Intrathecal morphine 122
vi
Palmer, Craig M. Handbook of Obstetric Anesthesia.
Oxford,, GBR: BIOS Scientific Publishers Ltd, 2002. p vi.
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Contents
Other intrathecal opioids 123
Continuous intrathecal analgesia 124
Patient-controlled analgesia (PCA) 124
Nonsteroidal agents (NSAIDs) 126
Conclusion 126
9. Pregnancy induced hypertension and preeclampsia
Kenneth E. Nelson and Robert D'Angelo 129
Introduction 130
Pathophysiology 130
Complications 132
Obstetric management 132
Anesthetic management 133
Anesthetic options 135
Summary 137
10. Hemorrhage in obstetrics
Craig M. Palmer 139
Introduction 140
Uteroplacental anatomy and normal delivery 140
Maternal hemorrhage: prepartum 140
Maternal hemorrhage: intrapartum 146
Maternal hemorrhage: postpartum 147
Uterotonics 149
Transfusion in obstetrics 150
11. Obesity
Medge Owen and Robert D'Angelo 153
Introduction 154
Pathophysiology 154
Pregnancy and obesity 155
Obstetric complications 155
Fetal complications 156
Anesthetic considerations 156
Analgesia for labor and delivery 157
Anesthesia for cesarean section 160
Summary 162
12. Complications of labor
Craig M. Palmer 163
Introduction 164
Prematurity and preterm labor 164
Multiple gestation 171
Abnormal presentation 173
Summary 175
vii
Palmer, Craig M. Handbook of Obstetric Anesthesia.
Oxford,, GBR: BIOS Scientific Publishers Ltd, 2002. p vii.
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Contents
13. Coexisting disease
Michael J. Paech, Craig M. Palmer, Laura S. Dean
and Robert D'Angelo 177
Introduction 178
Diabetes 178
Cardiac disease 179
Pulmonary disease 191
Neurologic and neuromuscular disease 193
14. Nonanesthetic drugs and obstetric anesthesia
Michael ]. Paech 199
Magnesium 200
Vasopressors 202
15. Complications of obstetric anesthesia and analgesia
Michael J. Paech 209
Post-dural puncture headache 210
Back pain 214
Infection 217
Epidural and subdural hematoma 218
Neurological deficit 219
High regional block 221
Intravenous injection of local anesthetic 225
Complications of general anesthesia 227
Medicolegal considerations 230
16. Neonatal resuscitation
Valerie Arkoosh 233
Introduction 234
Neonatal adaptation to extrauterine life 234
Requirements for effective neonatal resuscitation 235
Antepartum assessment of risk 236
Essentials of neonatal resuscitation 237
Summary 242
17. Obstetric anesthesia in the developing world
Paul M. Fenton 243
Introduction to the developing world 244
Manpower 245
Equipment 246
Obstetric practice and obstetric anesthesia 247
Common obstetric problems and procedures 249
Morbidity and mortality in obstetric anesthesia 253
Summary and conclusions 254
Index 257
viii
Palmer, Craig M. Handbook of Obstetric Anesthesia.
Oxford,, GBR: BIOS Scientific Publishers Ltd, 2002. p viii.
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Abbreviations
Ach acetylcholine IV intravenous
AMPA a-amino-3-hydroxy-5-4- IVC inferior vena cava
isoxazolepropionic acid IVH intraventricular hemorrhage
BP blood pressure LA local anesthetic
bpm beats per minute LBW low birth weight
CNS central nervous system LOR loss of resistance
CPD cephalopelvic disproportion MAC minimum alveolar concentration
CS cesarean section MLK myosin light-chain kinase
CSEA combined spinal-epidural anesthesia NMDA N-methyl-D-aspartate
CSF cerebrospinal fluid PCEA patient-controlled epidural
DIC disseminated intravascular anesthesia
coagulation PCIA patient-controlled intravenous
EA epidural anesthesia analgesia
EBP epidural blood patch PDPH post-dural puncture headache
ECG electrocardiogram PIH pregnancy-induced hypertension
ECV external cephalic version p.p.m. parts per million
EGA estimated gestational age PPV positive-pressure ventilation
FHR fetal heart rate PTL preterm labor
FRC functional residual capacity PVR pulmonary vascular resistance
GA general anesthesia RDS respiratory distress syndrome
HOCM hypertrophic obstructive SA spinal anesthesia
cardiomyopathy SVC superior vena cava
ICP intracranial pressure SVR systemic vascular resistance
IM intramuscular UPP uterine perfusion pressure
IUGR intrauterine growth retardation WDR wide dynamic range
ix
Palmer, Craig M. Handbook of Obstetric Anesthesia.
Oxford,, GBR: BIOS Scientific Publishers Ltd, 2002. p ix.
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Contributors
Valerie A. Arkoosh, MD
Associate Professor of Anesthesiology and Obstetrics & Gynecology, MCP Hahnemann Univer-
sity Philadelphia, PA, USA
Laura S. Dean, MD
Assistant Professor, Department of Anesthesiology, Wake forest University, Winston-Salem, NC,
USA
Paul Fenton, MD
Associate Professor of Anaesthesia, Malawi College of Medicine, Blantyre, Malawi, Africa.
Kenneth E. Nelson, MD
Assistant Professor, Department of Anesthesiology, Wake Forest University, Winston-Salem, NC,
USA
Medge D. Owen, MD
Assistant Professor, Department of Anesthesiology, Wake Forest University, Winston-Salem, NC,
USA
John A. Thomas, MD
Assistant Professor, Department of Anesthesiology, Wake Forest University, Winston-Salem, NC,
USA
X
Palmer, Craig M. Handbook of Obstetric Anesthesia.
Oxford,, GBR: BIOS Scientific Publishers Ltd, 2002. px.
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Preface
Obstetric anesthesia is a rapidly expanding and evolving field, and this is certainly not the first
book to address the subspecialty. When the idea of a completely new text was first raised, our
first questions were whether there was a need for a book, and how it would differ from previous
textbooks.
We saw a need for a practical guide to patient care and management, one that could be
consulted quickly (and often) to outline a concrete course of clinical management: how to manage
specific patients in specific situations, what drug to give, how to give it, how much to give, and
when to stop and try something different. Our goal in this book has been to provide anethesiol-
ogists and anesthetists, both in training and in practice, with that practical reference.
We have worked diligently to make the information easy to use—when possible, we have tried
to distill essential information down into tables, charts, diagrams, and flowcharts which can be
quickly accessed and applied. We have tried to limit the discussion to the essential background,
rationale, and science behind clinical decision-making. This is not intended to be an exhaustive
reference textbook, though the readings and references at the end of each chapter do provide
additional background and the basis for further study.
Of course, as the saying goes, ", . . there is more than one way to skin a cat." Where our expe-
rience has shown one approach works best, we have advocated it; where there are equally viable
options, we have tried to present each, with the advantages and disadvantages of alternate
approaches.
All three of us are full-time clinical obstetric anethesiologists, as are most of our contributors.
We care for these patients and deal with these problems everyday. The Handbook of Obstetric
Anesthesia draws on our experience and study to tell you what we do, how we do it and why.
Craig M. Palmer, M.D.
Robert D'Angelo, M.D.
Michael J. Paech, FANZA
xi
Palmer, Craig M. Handbook of Obstetric Anesthesia.
Oxford,, GBR: BIOS Scientific Publishers Ltd, 2002. pxi.
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