Obstetric Analgesia and Anesthesia A Manual for Physicians, Nurses and Other Health Personne4 Prepared for the World Federation of Societies of Anaesthesiologists Edited by John J. Bonica With 24 Figures Springer-Verlag Berlin Heidelberg New York 1972
JOHN J. BONICA, M. D. University of Washington, School of Medicine, Department of Anesthesiology and Anesthesia Research Center, Seattle/USA Chairman, Ad Hoc Committee for Obstetric Anesthesia, and Scientific Advisory Committee WFSA ISBN 978-3-642-49523-6 ISBN 978-3-642-49813-8 (ebook) DOl 10.1007/978-3-642-49813-8 The use of general descriptive names, trade marks, etc. in this publication, even if the former are not especially identified, is not to be taken as a, sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopying, machine or similar means, and storage in data banks. Under 54 of the German Copyright Law where copies are made for other than private use, a fee is payable to the publisher, the amount of the fee to be determined by agreement with the publisher. by Springer-Verlag Berlin. Heidelberg 1972. Library of Congress Catalog Card Number 72-86713.
Introduction The provision of the best possible anesthetic care to the-greatest number of patients all over the world has always been the main goal of the World Federation of Societies of Anaesthesiologists. In addition to the establishment of Regional Anesthesiology Training Centers and the organization of Regional and World Congresses, the distribution of practical monographs on some important aspects of anesthesiology were considered important for the attainment of this objective. In 1968, on the occasion of the Fourth World Congress of Anesthesiology, held in London, a monograph on "Emergency Resuscitation", compiled by the Committee on Cardiopulmonary Resuscitation, chaired by Professor HENNING POULSEN, was made available to our membership. Subsequently, this excellent monograph was translated into Spanish, Russian, German and French and to this date over 100,000 copies of it have been distributed to anesthesiologists and other interested physicians the world over. When looking for a suitable topic for a second monograph to commemorate the 1972 World Congress of Anesthesiology to be held in Kyoto this September, the subject of Obstetric Analgesia and Anesthesia was the first choice of almost everyone consulted. For reasons that are hard to condone, obstetric analgesia and anesthesia has often been the stepchild among the anesthetic subspecialties. Considering that one fourth to one third of all anesthesias administered are for the relief of childbirth, that obstetric anesthesia is in many cases "emergency" anesthesia, and that not one but two lives are at stake, it is difficult to acquiesce in the fact that in many communities this important function, deserving the skill and devotion of the best specialists, is often relegated to poorly trained medical and paramedical personnel. In an attempt to alleviate this deplorable situation, an Ad Hoc Committee for Obstetric Anesthesia was appointed and charged with the task of compiling a brief, but comprehensive, practical monograph on obstetric pain relief and infant resuscitation. This monograph is the result of many hours of hard work contributed by the members of this committee, ably directed by Professor John Bonica. It is our hope that this concise volume will accomplish two objectives: It will arouse a world wide interest in the sadly neglected field of obstetric anesthesia and will serve as a practical guide for those planning to devote more III
time, energy and sophistication to the relief of the suffering of parturients and the improvement of chances of the newborn for a healthier and thereby happier life. FRANCIS F. FOLDES, M. D. President World Federation of Societies of Anaesthesiologists IV
Preface In recent years there has been an impressive surge of interest in obstetric analgesia and anesthesia. This trend is exerting social and professional pressures on physicians to provide parturients with better and more widespread pain relief during childbirth. Of the many factors for this trend for greater demand for, and use of, anesthesia for childbirth, one of the most important: has been the expectation of parturients. Today, gravidas in many countries, having been made aware of the benefits of good obstetric analgesia by magazine articles, books, television and other news media, have come to expect it just as they expect painless surgery and painless dentistry. Thisincreased demand by patients and the realization that lack of anesthesia or poorly administered anesthesia in themselves cause maternal and perinatal mortality and morbidity have prompted obstetricians in many parts of the world to demand better services by anesthesiologists. This expectation is strongly supported by statistics from those medical centers where obstetric anesthesia is provided by competent personnel. These data show that optimal pain relief not only does not contribute to, but actually reduces maternal and perinatal mortality and morbidity by permitting better obstetric care. In response to this, more and more physician-anesthetists are devoting some of their professional time to obstetric anesthesia and some have become "obstetric anesthesiologists," physicians with special training who are devoting all of their efforts to this field. This booklet is intended to provide guidelines to people who have the serious responsibility of administering obstetric analgesia-anesthesia, whether they be physicians, nurses or midwives. The importance of fundamental knowledge in managing parturients cannot be overemphasized, and is attested by the rather large amount of space devoted to Chapter 1. Since normal vaginal delivery occurs in over three-fourths of births, a commensurate amount of space is devoted to this aspect of obstetrics. The sections on operative and complicated deliveries consider only the most common problems. The scope of the brochure and space limitations preclude discussion of every drug and technique used throughout the world or detailed review of the literature of the methods mentioned. The reference list at the end of the brochure should be consulted for comprehensive reviews. v
I wish to thank the members of the Ad Hoc Committee, but especially Doctors Gertie Marx and Sol Shnider, for their cooperation and help in the development of this brochure. The Committee hopes that it will encourage better anesthetic care for mothers and their offspring everywhere. Seattle, June 1972 JOHN J. BONICA, M. D. Chairman, Ad Hoc Committee for Obstetric Anesthesia, and Scientific Advisory Committee WFSA VI
Table of Contents Part A. Fundamental Considerations Chapter 1. Physiologic and Pharmacologic Considerations 1 Maternal Physiology and Psychology 1 Physiology and Pharmacology of the Placenta and Fetus... 14 Physiology of the Forces of Labor... 21 Pharmacology of Obstetric Analgesics, Anesthetics and Related Drugs... 23 Part B. Analgesia-Anesthesia for Normal Labor and Vaginal Delivery Chapter 2. General Considerations 29 Basic Principles 29 Antepartal Preparation 30 Preanesthetic Care 34 Intraanesthetic Care 35 Postanesthetic Care 35 Chapter 3. Non-Pharmacologic Methods of Obstetric AnalgeSIa... 36 Psychologic Analgesia..... 36 Acupuncture Analgesia..... 42 Chapter 4. Simple Methods of Obstetric Analgesia 43 Management During Latent Phase. 43 Analgesia During the Active Phase of Labor 45 Chapter 5. Regional Analgesia-Anesthesia 48 Basic Considerations 49 Paracervical Block '..... 54 Pudendal Block... 56 Subarachnoid (Spinal) Anesthesia 58 Spinal Epidural Block... 60 Caudal Block........... 68 Cqp1plications of Regional Anesthesia 70 Chapter 6. General Analgesia-Anesthesia 75 Basic Considerations 75 Inhalation Analgesia 77 General Anesthesia. 82 VII
Part C. Analgesia-Anesthesia for Complicated Obstetrics Chapter 7. Chapter 8. Chapter 9. Chapter 10. References.. Anesthesia for Operative Vaginal Delivery Forceps Delivery Breech Delivery.... Multiple Delivery.... Other Operative Obstetric Procedures Anesthesia for Cesarean Section Elective Cesarean Section.... Emergency Cesarean Section Anesthesia in the Presence of Complications Toxemia of Pregnancy Heart Disease Diabetes Mellitus Prematurity Fetal Distress.. Management of Newborn Basic Considerations General Management Resuscitation of the Depressed Newborn 87 87 89 92 93 95 95 100 102 102 107 111 113 114 117 117 120 122 127 VIII