Obstetric Analgesia and Anesthesia

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Labour Analgesia

  1. Early initiation of neuraxial analgesia can help prevent aggravation of respiratory symptoms due to labour pains and can minimize the use of general anesthesia in intrapartum Caesarean section.
  2. Neuraxial procedures that involve puncturing dura mater may minimize the need for rescue general anesthesia in cases of urgent Caesarean section; consider CSE or DPE.
  3. Platelet count is recommended when the patient is admitted. The threshold (70,000 x 106/L) for neuraxial placement should be more lenient at this time given that the respiratory risks of general anesthesia likely exceed the risks of epidural hematoma.
  4. It is reasonable to avoid patient-controlled IV Remifentanil/Fentanyl.
  1. Use of nitrous oxide involves risks of aerosolization; its use should be discussed and potentially suspended. A microbiological filter should be used.

 

Caesarean Section Anesthesia

  1. Neuraxial anesthesia is preferred (in the absence of usual contraindications) to general anesthesia because it minimizes the risks of pulmonary exacerbation and of aerosol transmission during the intubation process.
  2. The occurrence of inordinate intraoperative hypotension with neuraxial anesthesia was inconsistent from one study to another.
  3. Emergency situations should be avoided as much as possible. Wearing adequate PPE requires supplementary planning. Early intubation is advised in cases of respiratory distress.
  4. Communication between specialists is important to allow for enough time to administer a surgical block if needed for emergency Caesarean delivery.

Precautions

  1. Level III PPE seems to have limited transmission to anesthetists who were in contact with mild cases for administration of regional anesthesia.
  2. Limited staff should be present in the OR. Two pairs of gloves are recommended for any procedure, and the outer pair should be replaced post-intubation.
  3. Airborne PPE precautions should be used during intubation and extubation for staff present in the OR.
  4. An experienced anesthetist should perform the procedures ideally.
  5. Use a circuit extension with HEPA filter on the patient side for pre-oxygenation, and use a closed suction unit if possible.
  6. Employ measures to improve chances of intubation on the first try and prevent bag-mask ventilation. 

Post-operative Considerations

  1. The use of NSAIDS is controversial at this time. Their effects in the setting of postpartum pain are not known. NSAIDS are reasonable in mild or asymptomatic infections where pain management is inadequate with Acetaminophen. 
  2. Envisage avoiding Dexamethasone as an antiemetic to treat PONV in suspected or confirmed cases.

 

This information comes from multiple records. Bauer at al. provide recommendations and expert opinions regarding obstetric anesthesia and other obstetric topics in a review. Chen R. et al. conducted a retrospective analysis of 17 pregnant women diagnosed with COVID-19 who underwent Caesarean delivery at the Renmin hospital of Wuhan University in Wuhan, China from January 30, 2020 to February 23, 2020.  Among these parturients, 14 received continuous epidural anesthesia and 3 were administered general anesthesia with tracheal intubation for emergency surgery due to fetal distress. The Faculty of Intensive Care Medicine alongside The Intensive Care Society, The Association of Anaesthetists, The Royal College of Anaesthetists and The Obstetric Anaesthetists’ Association produced a guidance document regarding labour analgesia and Caesarean section anesthesia. Heesen et al. conducted a review and meta-analysis to the effectiveness of CSE and epidural analgesia for labour purposes. Qi et al. provided a consensus of experienced obstetricians in Wuhan, China who have managed deliveries in pregnant women with confirmed or suspected COVID-19. The Society for Obstetric Anesthesia and Perinatology released an expert opinion providing recommendations for obstetric anesthesia and precautions. The Université de Montréal Département d’anesthésiologie et de médecine de la douleur have created various documents outlining directives and guidelines for anesthesia use during the pandemic. Zhong et al. performed a retrospective analysis of 49 patients with COVID-19 at the Zhongnan Hospital in Wuhan, China who received spinal anesthesia for Caesarean delivery (45) or orthopedic surgery (4). Risk of transmission to anesthetists was also assessed.

Sources:

  1. Bauer M., Bernstein K., Dinges E. et al. (April 6, 2020). Obstetric Anesthesia During the COVID-19 Pandemic. Anesthesia & Analgesia. https://doi.org/10.1213/ANE.0000000000004856
  2. Chen R., Zhang Y., Huang L. et al (16 March 2020). Safety and efficacy of different anesthetic regimens for parturients with COVID-19 undergoing Cesarean delivery: a case series of 17 patients. Canadian Journal of Anesthesia. https://doi.org/10.1007/s12630-020-01630-7
  3.  The Faculty of Intensive Care Medicine, Intensive Care Society, Association of Anaesthetists, Royal College of Anaesthetists, Obstetric Anaesthetists’ Association (March 16, 2020). Obstetric anesthesia guidance: Management of pregnant women with known or suspected COVID-19. Retrieved from: https://icmanaesthesiacovid-19.org/management-of-pregnant-women-with-known-or-suspected-covid-19
  4. Heesen M., Van de Velde M., Klöhr S. (January 2014). Meta-analysis of the success of block following combined spinal-epidural versus epidural analgesia during labour. Anaesthesia.  https://doi.org/10.1111/anae.12456
  5.  Qi H., Luo X., Zheng Y., et al. (March 26 2020). Safe Delivery for COVID-19 Infected Pregnancies. BJOG: An International Journal of Obstetrics & Gynaecology. https://doi.org/10.1111/1471-0528.16231
  6. The Society for Obstetric Anesthesia and Perinatology (April 5, 2020). Interim Considerations for Obstetric Anesthesia Care Related to COVID-19. Retrieved from: https://soap.org/education/provider-education/expert-summaries/interim-considerations-for-obstetric-anesthesia-care-related-to-covid19/
  7. Université de Montréal : Département d’anesthésiologie et de médecine de la douleur. COVID-19.  Retrieved from : https://anesthesiologie.umontreal.ca/covid-19/
  8.  Zhong Q., Lui Y.Y., Luo Q. et al. (March 28, 2020). Spinal anaesthesia for patients with coronavirus disease 2019 and possible transmission rates in anaesthetists: retrospective, single-centre, observational cohort study. British Journal of Anaesthesia. https://doi.org/10.1016/j.bja.2020.03.007
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