Obstetric Anesthesia and Analgesia
Core concepts
Understand the physiologic changes affecting anesthesia: increased epidural venous plexus engorgement, decreased local anesthetic requirements, aspiration risk, and airway edema. Know the indications, contraindications, and complications of neuraxial analgesia (epidural, spinal, combined spinal-epidural). Understand labor analgesia options and the role of patient-controlled epidural analgesia. Know the management of post-dural puncture headache and the role of epidural blood patch.
Understand anesthesia for cesarean delivery: neuraxial versus general anesthesia, and the considerations for difficult airway and failed intubation. Know the implications of obstetric hemorrhage for anesthesia and the role of massive transfusion protocols. Be familiar with medication safety in lactation and the transfer of anesthetics into breast milk.
Traps
- Assuming all patients are candidates for neuraxial analgesia; check coagulation status and infection.
- Forgetting that pregnancy lowers local anesthetic requirements.
- Missing that post-dural puncture headache can be treated conservatively first, with blood patch for persistent cases.
- Overlooking that general anesthesia in pregnancy carries higher aspiration and difficult airway risk.
- Assuming all analgesics are safe in lactation; check compatibility.
Rule of thumb
For any anesthetic decision, weigh maternal safety, fetal safety, and the urgency of delivery. Neuraxial techniques are preferred when feasible; general anesthesia is reserved for contraindications or emergencies.
Worked example: A patient requests labor analgesia but has a platelet count of 80,000. Assess coagulation status and the cause; neuraxial analgesia may be deferred or modified depending on the clinical picture and institutional protocol.