1. In The Name of GOD M. A. Attari, MD. Associated Professor of Anesthesiology Medical University Of Isfahan ma_attari@yahoo.com

2. Obstetric analgesia for normal delivery and anesthesia methods for Cesarean section in Isfahan-IRAN

4. In our province approximately 60% of parturient get delivery by cesarean section, while in the our country as a whole is 46% and in south east of IRAN in Zabol near to the Pakistan is about 4%.

5. The usual methods of analgesia for Vaginal Delivery is: o Inhalation analgesia o Systemic narcotics o Tranquilizers / hypnotics o Acupuncture o TENS o Psychoanalgesic techniques

6. TECHNIQUES OF LABOR ANALGESIA Continuous epidural analgesia Patient-controlled epidural analgesia (PCEA) Combination of the above two techniques Combined spinal-epidural analgesia (CSE) Spinal opiates Intermittent epidural bolus injections

7. Inhalation Analgesia for Vaginal Delivery Advantages: Easy to administer (no needles or PDPH) “Satisfactory” analgesia variable Minimal neonatal depression (N 2 O 30-50%; very low concentration volatile agents)

8. Inhalation Analgesia for Vaginal Delivery Disadvantages: Decreased uterine contractility (except N 2 O) Rapid induction of anesthesia in pregnancy Risk of unconsciousness and aspiration Difficulties with scavenging in labor rooms (N 2 O 30-50%; very low concentration volatile agents)

11. Pain Intensity with and without Entonox Pain Relief percentage Pain Intensity

13. Analgesia for Labor and Delivery Local infiltration Pudendal block Paracervical block Paravertebral (lumbar sympathetic block) Epidural - lumbar (caudal) Spinal Combined spinal-epidural (CSE) Local and regional techniques

14. Continuous Infusion Epidural A larger volume of a more dilute agent is more effective for labor analgesia than a smaller volume of higher concentration PCEA Good analgesia Good analgesia Patient autonomy Patient autonomy Less need for MD interventions Less need for MD interventions Cost effective Cost effective

16. Strategies to Decrease Complications with CSE Decrease dose of opioid: – Fentanyl 15-20 µg – Sufentanil 2.5-5 mg Combine with: – Local anesthetic (bupivacaine 1.25-2.5 mg) – Epinephrine

17. Controversial Areas Effects on labor and delivery process Maternal temperature elevation Drug choice - are new agents better? Epidural vs. CSE

18. LOCAL ANESTHETICS Continuous infusion: Bupivacaine 0.0625%-0.25%-8 -15 ml/hr Ropivacaine: 0.125%-0.25%- 6 -12 ml/hr Lidocaine: 0.5%-1% -8-15 ml/hr 2-chloroprocaine 0.75% -27 ml/hr Intermittent bolus injections: Bupivacaine: 0.125%-0.375%, 5-10 ml, duration:1-2 hr Ropivacaine: 0.125%-0.25%, 5-10 ml, duration: 1-2 hr Lidocaine: 0.75%-1.5%, 5-10 ml, duration: 1-1.5 hr 2 chloroprocaine 1-2%, 5-10 ml, duration: 0.75-1 hr

19. EPIDURAL ANALGESIA Disadvantages: Not instant in onset May be associated with motor block Postdural puncture headache (50-85% with 16 or 18- G Tuohy’s needle)

20. LEVEL OF BLOCK High Level: Can result from high dose or subdural/subarachnoid migration of catheter Low level: Can result from intravenous migration of catheter, catheter outside the epidural space or administration of inadequate dose of local anesthetic

21. CONTINUOUS EPIDURAL INFUSION Still used routinely at many centers Good pain relief Less motor block Maternal and neonatal drug concentrations safe if used cautiously We routinely use either 0.0625% bupivacaine+fentanyl 2.5 μg/ ml at 12 ml/hr (early labor)+demand dose: 4 ml q 15 min 0.125% bupivacaine+fentanyl 2 μg/ml at 8 ml/hr (advanced labor)+ demand dose : 3 ml q 15 min

22. PATIENT CONTROLLED EPIDURAL ANALGESIA Advantages: Flexibility and benefit of self administration Ability to minimize drug dosage Reduced demand on professional time Disadvantages: May provide uneven block Addition of a basal infusion provides: More even block producing greater patient satisfaction

23. Are We Doing Enough? Facemasks Prep solution (Betadine) Gloves Bacterial Filter Filtered Needle

24. Hand Care Washing with alcohol based solution Artificial nails – Gram-negative pathogens on their fingertips Jewelry – Areas under rings more heavily colonized that comparable areas

26. Conclusions Individualize technique to patient’s goals and stage of labor Optimize management for spontaneous delivery Provide safe, cost-effective analgesia

28. Point