Skip to Main Content




A thorough understanding of the nature of the parturient’s pain is the first aspect in providing optimal obstetric anesthetic care. Once the biology and pathophysiology of this special acute pain is discussed, the benefits of analgesia for this pain will appropriately follow. Pharmacology of local anesthetics and related drugs will be reviewed, with special emphasis on complications associated with their administration. A variety of techniques including epidural, subarachnoid, and other regional techniques will be discussed with benefits and complications reviewed. General anesthesia for cesarean section delivery will be outlined. A variety of special consideration patients will be addressed, including: (1) the preeclamptic patient, (2) preterm birth patient on tocolytics, (3) human immunodeficiency virus (HIV)–positive mothers, (4) coagulopathies, (5) cardiac disease, and (6) pulmonary disease.




The current concept of pain focuses on the peripheral nervous system relaying a stimulus to the central nervous system (CNS) for interpretive evaluation—the somatosensory system (Fig. 20-1). The peripheral system consists of afferent neurons that are embedded in body tissues awaiting nociceptive (painful) stimuli. These afferent neurons are termed Ad (A-delta) and C-fibers. These fibers transverse into the spinal segments and synapse at the dorsal spinal ganglion. Here, substance-P is released causing the painful effect to be initiated. From each spinal segment stimulated, these messages ascend through one of two pathways to the thalamus for further modulation: the lateral spinothalamic tract or the medial lemniscus tract. Once at the thalamus, adjustment and regulation from inherent emotional and psychological factors occur. The data support the emphasis on the importance of perceptual factors that influence a patient’s total pain experience (Table 20-1). The psychodynamics of prior experience, motivation, anxiety, anticipation of pain, attention, personality, and ethnic and cultural factors all influence the modulation of substance-P release, affecting the pain experience. From the thalamus, this information is synthesized in the sensory cortex for relay to the many effector sites that contribute to the pain response. Once pain has been perceived, there is an initiation of the pain response that has neuroendocrine, behavioral, and psychological implications.

FIGURE 20-1.

Schematic of the somatosensory system.

Graphic Jump Location
Table Graphic Jump Location
TABLE 20-1.Pain Perception

In humans, there is a 300% to 600% increase in epinephrine and 200% ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.


Create a Free MyAccess Profile

* Required Fields

Note: If you have registered for a MyAccess profile on any of the Access sites, you can use the same MyAccess login credentials across all sites.

Passwords must be between 6 and 40 characters long (no whitespace), cannot contain characters #, &, and must contain:
  • at least one lowercase letter
  • at least one uppercase letter
  • at least one digit

Benefits of a MyAccess Profile:

  • Remote access to the site off-campus on any device
  • Notification of new content via custom alerts
  • Bookmark your favorite content such as chapters, figures, tables, videos, cases and more
  • Save and download images to PowerPoint
  • Self-Assessment quizzes saved for quick review
  • Custom Curriculum access for both instructors and learners

Pop-up div Successfully Displayed

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