The practice of obstetric anesthesia began in 1847 when Sir James Young Simpson introduced ether, or “twilight sleep,” into obstetric practice for the final stages of labor and delivery. Today obstetric anesthesia has evolved into a complex subspecialty. Although the majority of deliveries are uncomplicated, parturients are presenting with increasingly complex comorbidities because of medical and surgical advances in the treatment of their underlying conditions. For any hospital providing obstetrical care, the availability of qualified personnel and equipment to provide general or neuraxial anesthesia is essential for good obstetric care. Modern regional anesthetic techniques have contributed to maternal and neonatal safety. Persons administering or supervising obstetric anesthesia must be qualified to manage the rare but potentially life-threatening complications of neuraxial anesthesia, which include respiratory failure and cardiovascular collapse, local anesthetic toxicity including seizures, or vomiting and aspiration.
This chapter provides an overview of the physiologic changes seen with pregnancy, describes commonly used methods of labor analgesia, and provides an overview of anesthetics administered during pregnancy for cesarean section and nonobstetric surgery.
PREPARATION FOR PAIN DURING LABOR
The experience of birthing a child is personal and unique to each parturient. Each woman’s expectations of labor will influence the birthing experience. The experience of pain during labor is highly variable. In a meta-analysis of 10 studies that looked at the ability to cope with pain during labor, both the presence of individualized support throughout labor and an acceptance of pain during birth were found to be important. Pain management during labor involves more than the timely administration of analgesics. Some women may seek out nonpharmacological therapies to cope with the pain of labor, which may be independent of or complementary to the more traditional forms of labor analgesia. It is important to understand and respect the patient’s wishes and beliefs, regardless of culture and background.
The majority of parturients experience moderate to severe pain during labor and delivery, which they describe as being more intense than any other previous pain experience. Women who deliver for the first time describe the pain as more intense than that of subsequent labor. It is reported that the pain is exceeded only by traumatic amputation or causalgia.
The American Society of Anesthesiologists (ASA) states:
There is no other circumstance where it is considered acceptable for an individual to experience untreated severe pain, amenable to safe intervention, while under a physician’s care. In the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief during labor.
Control of pain during labor should begin with prenatal education and counseling. Lack of proper psychological preparation can contribute to the pain experienced with birth. Considerable evidence exists that preparation for childbirth can significantly modify the amount of pain experienced. Continuous support throughout labor is associated with increased satisfaction with the birth experience and less ...