Modern anesthesia in obstetrics as a component of the concept of safe anesthesia
Authors: Tkachenko R.O. 
Published: July 2021

Background. Anesthesia should be selected individually for each labor. Systemic analgesia of labor includes suggestive analgesia, narcotic analgesics, local infiltration and regional blockade, inhalation analgesia. It should be noted that there is no analgesic, sedative or local anesthetic that does not penetrate the placenta, affecting the fetus in any way.

Objective. To describe modern anesthesia in obstetrics.

Materials and methods. Analysis of literature sources on this issue.

Results and discussion. Three groups of antispasmodics are used for analgesia: neurotropic (atropine, scopolamine), myotropic (papaverine, drotaverine) and neuromyotropic (baralgin). The main non-steroidal anti-inflammatory drugs used for this purpose include metamizole sodium, ketorolac tromethamine, diclofenac sodium. Inhalation autoanalgesia with nitrous oxide (N2O) is effective only in 30-50 % of women. When the concentration of N2O exceeds 50 %, the sedative effect increases and oxygenation decreases, which leads to the loss of consciousness and protective laryngeal reflexes. Such analgesia is indicated for low-risk patients who have refused from regional anesthesia. Epidural anesthesia (EDA) is the gold standard of labor anesthesia. The advantages of EDA include the option to change the degree of analgesia, the ability to continue pain relief until the end of labor and the minimal impact on the condition of both child and mother. Before manipulation, be sure to determine the platelet count and heart rate of the fetus. It is recommended to start EDA in the latent stage of labor. In patients with uterine scarring, early EDA is a mandatory component of medical care. The woman’s wish is the main indication for EDA. Indications for early catheterization of the epidural space include the presence of twins, preeclampsia, obesity, respiratory tract with special features. Headache is the most common complication of EDA. The use of pencil-point spinal needles minimizes the frequency of this complication. Adequate analgesia for uncomplicated labor should be performed with minimal concentrations of anesthetics with the least possible motor block. Local anesthetics (lidocaine, bupivacaine (Longocaine, “Yuria-Pharm”), ropivacaine) are used for EDA). Combined spinal-epidural anesthesia provides a rapid effect and long-term analgesia. For this purpose, 0.25 % Longocaine heavy (“Yuria-Pharm”) 2 mg and fentanyl 20 μg are administered intrathecally, followed by 0.225 % Longocaine 10 mg and fentanyl 20 μg epidurally. The technique of epidural dural puncture is a modification of combined spinal-epidural anesthesia. This technique improves the caudal spread of analgesia compared to the epidural technique without the side effects seen with spinal-epidural anesthesia. The ideal local anesthetic should be safe for both mother and fetus, provide sufficient analgesia with minimal motor block, and not affect labor process. A single spinal injection of opioids may be effective, but it should be limited in time. The use of systemic opioids during labor increases the need for resuscitation of newborns and worsens the condition of their acid-base balance compared to basic regional anesthesia. Catheter techniques can be used in case of the increased labor duration. Nalbuphine (“Yuria-Pharm”), which eliminates the side effects of regional anesthesia, can also be successfully used. Analgesic effect of paracetamol (Infulgan, “Yuria-Pharm”) in case of intravenous administration exceeds the analgetic effect of tramadol, and the effect on the newborn condition according to the Apgar scale does not differ (Meenakshi et al., 2015). Paracetamol (Infulgan) is moderately effective for perineal pain on the first day after delivery. The possibility of use during lactation is an another advantage of paracetamol.

Conclusions. 1. Pain during labor is an extremely stressful factor, so women should have access to quality analgesia and anesthesia. 2. There is no analgesic, sedative or local anesthetic that does not penetrate the placenta, affecting the fetus. 3. EDA is the gold standard of labor anesthesia. 4. Combined spinal-epidural anesthesia provides rapid effect and long-term analgesia. 5. The use of systemic opioids during labor increases the need for resuscitation of newborns and worsens the condition of their acid-base balance. 6. Nalbuphine and Infulgan have been used successfully for labor pain relief.