This document discusses complications that can arise from regional anesthesia techniques used in obstetrics. It notes that while regional anesthesia is widely used and generally safe, complications do occur. Some complications include adverse physiological responses, issues related to needle/catheter placement like dural puncture and post-dural puncture headache, neurological injuries, infections, and drug toxicity. It provides details on specific complications like hypotension, bradycardia, urinary retention, and effects on the second stage of labor. Overall, the document provides an overview of potential complications from regional anesthesia in obstetrics.
2. Regional anaesthesia is a safe and widely
utilised method of analgesia for labour.
The majority of caesarean sections are
managed using spinal (intrathecal), epidural
or combined spinal / epidural (CSE)
techniques.
Although serious complications are
uncommon with regional anaesthesia, they
must be considered and should be discussed
with the patient.
3. Over 100 years ago August Bier performed
the first recorded spinal anaesthetic
complications from the use of regional
anaesthesia have been described over this
same period of time
Bier also being the first to describe a ‘spinal’
or ‘post dural-puncture headache’
4. In 1950’s decline in use of neuraxial technique
due its complications
over the last thirty years the increased use of
regional anaesthesia for caesarean section due
to its increased safety
General anaesthesia is now used in less than
5% of caesarean sections
There are still a number of important
complications that are associated with regional
anaesthesia and analgesia
5. COMPLICATIONS OF NEURAXIAL ANAESTHESIA
Adverse or exagerrated physiological
responses
Complications Related To Needle/ Catheter
Placement
Drug Toxicity
6. ADVERSE OR EXAGERRATED PHYSIOLOGICAL
RESPONSES
Urinary retention
High block
Total spinal anesthesia
Cardiac arrest
Anterior spinal artery syndrome
Horner's syndrome
9. DRUG TOXICITY
Systemic local anaesthetic toxicity
Transient Neurological Symptoms
Cauda Equina Syndrome
10. HYPOTENSION
Defined as a 20-30% decrease in systolic BP
or systolic BP less than 100 mm Hg
Occurs due to sympathetic blockade leading
to vasodilatation
Aorto-caval compression
Incidence & severity depends on
Height of block
Position of parturient
Whether prophylatic measurements taken to
avoid such hypotension
11. Measures to decrease risk of Hypotension
Intravenous administration of fluids
Avoidance of aorto caval compression
Vigilant monitoring of BP at frequent
intervals
Uterine blood flow is directly dependant on
maternal blood pressure
FHR evaluation is helpful
12. Treatment
Administration of iv crystalloids
Placement of mother in full lateral position
Administration of supplimental oxygen
Incremental dose of ephedrine(5-10 mg)
Why phenylepherine?
13. BRADYCARDIA
Most commonly after spinal anaesthesia
May progress to Complete heart block or
asystole
Caused by blockade of preganglionic cardiac
accelerator fibers (T1-T4)
Decrease in venous return leading to
decrease action of right atrial stretch
receptors
Usually responds to iv atropine
14. ACCIDENTAL DURAL PUNCTURE
Common & problematic complication of epidural
placement
Incidence upto 3%
Can lead PDPH upto 70% cases
May be detected at the time of insertion of
epidural needle or after placement of the
catheter
Management is to remove the needle &
reposition the catheter at a different interspace
Placement of a catheter in the subarachnoid
space to become a continuous spinal technique
15. SPINAL HEADCHE CAN BE REDUCED BY
Injection of CSF from the epidural syringe back
into the subarachnoid space through needle
Insertion of an epidural catheter into
subarachnoid space
Injection of preservative free NS through
intrathecal catheter beforeits removal
Adminstration of continuous intrathecal labor
analgesia
Leaving the intrathecal catheter insitu for a total
of 12 to 20 hrs
16. POST DURAL PUNCTURE HEADACHE(PDPH)
Incidence :0.5-2% for spinal
1-7.6% for epidural
PDPH has typical feature of postural headche
that is worsened by standing / staining &relieved
by lying down
Aetiology
Due to CSF leaking through dural puncture
site, leading to intracranial hypotension.
This causes settling of brain & strecthing of
intracranial nerves, meninges,blood vessels
17. DIAGNOSIS
Severe , disabling fronto-occipital headache
with radiation to the neck & shoulders
Presents 12 hrs or more after dural puncture
Worsens on sitting & standing ,relieved by
lying down & abdominal compression
May be associated photophobia, vertigo,
nausea & vomiting, diplopia, hearing loss,
tinnitus. Convulsions & visual field efects
19. MANAGEMENT OF PDPH
Conservative
Bedrest
Encourage oral fluids & or intravenous
hydration
Caffeine – either iv (eg: 500 mg caffeine in 1
litre saline) or orally
Regular analgesia
Reassurance
20. Interventional - Epidural patch
First described more than 40 yrs ago
Most effective treatment of PDPH
Injecting 20 ml of patient’s own blood into
epidural space near puncture site
Form a clot obstructing dural tear
Causes increase in CSF pressure & cerebral
vasoconstriction
Success rate only 61 %
21. TOTAL SPINAL BLOCK
After excessive cephalic spread of local anaesthetic
Can occur during single shot spinal anasthesia
Inadvertent intrathecal spread of epidural medication
after unintentional dural puncture or catheter
migration
Subdural spread of local anaesthetic can also cause
a high block characterised by
high sensory level
sacral sparing
incomplete / absent motor block
22. Symptoms
Hypotension
Dyspnoea
Inability to speak & loss of consciousness
Numbness or weakness of hand
Nasal mucosa become engorged
23.
24. INTRAVASCULAR INJECTION OF LOCAL
ANAESTHETIC
CNS symptoms :
restlessness,diziness,tinnitus,perioral
parasthesia, difficulty in speaking, seizures, loss of
conciousness
CARDIOVASCULAR EFFECTS
May progress from increased blood pressure to
bradycardia,
Depressed ventricular function & ventricular
tachycardia and fibrillation
MATERNAL CONVULSION were the single most
common untoward event
25.
26. INADEQUATE ANALGESIA
Failure rate of epidural analgesia ranges
from 1.5% to 5 % depending on the skill of
the anaesthetist
27.
28. NEUROLOGIC COMPLICATIONS
Direct trauma to spinal cord is very rare
Nerve root trauma
Cauda equina syndrome / adhesive
arachnoiditis are due to chemical toxicity
Thrombosis of anterior spinal artery may lead
to motor weakness or paralysis & loss of pain
& temparature sensation
29. CENTRAL NERVOUS SYSTEM INFECTIONS
Infection may be exogenous in origin caused by
contamination of equipment or pharmacologicalic
agents or by colonisation of catheter
Endogenous spread may occur from a site of
infection elsewhere in the body
Epidural abscess
1 in 10000 cases
Fever , backpain, localized infection at the level of
epidural site 2 to 3 days after procedure
Meningitis
may be associated with bacteraemia
30. SPINAL & EPIDURAL HAEMATOMA
Incidence
1 in 150000 for epidural
1 in 220000 for spinal
Risk Factors
Low platelet count
INR level above 1.4
Use of anticoagulants & thromboprophylaxis with
LMWH
Recent guidelines is to defer regional technique 10- 12
hrs in a parturient who has received preoperative
LMWH OR 24 hrs for those receiving higher dose of
LMWH
31. BACKACHE
Low backache is common after delivery
3-45 % women receiving epidural
40% for spontaneous vaginal delivery
25% for instrumantal delivery
Factors which may predispose for increase incidence in
epidural
Use of larger needle
Supraspinous ligament haematoma
Difficult identification of epidural space
Prolonged assumption of a unnatural position during labor
or delivery
Sacroilaiac strain
32. TRANSIENT NEUROLOGICAL SYMPTOMS
First described in 1993
Also known as transient radicular irritation
Characterized by backpain radiating to the legs
without sensory or motor deficits
Occuring after resolution of spinal block & resolving
spontaneously within several days
Most commonly seen with HYPERBARIC
LIDOCAINE(11.9%)
Also reported with
tetracaine(1.6%),bupivacaine(1.3%),mepivacaine ,
prilocaine,procaine,ropivaciane
33. Incidence is highest among outpatients(early
ambulation) after surgery in the lithotomy
position & lowest among inpatients in
positions other than lithotomy
Pathogenesis is believed to represent
concentration dependant neurotoxicity of
local anaesthetics
34. URINARY RETENTION
Role of epidural analgesia in urinary retention is
unclear
Obstetric factors
Long labor
Edema
Instrumental delivery
Perineal trauma
Haematoma
pain
35. NAUSEA & VOMITING
Is usually associated with hypotension due to
spinal blockade
Responds to treating of hypotension
May be also due surgical stimuli such as
traction of peritoneum
Associated with use of opioids
36. EFFECTS ON 2ND STAGE OF LABOR &
CAESAREAN SECTION
Mainly two controversies
Whether it prolongs 2nd stage of labor?
Whether it increases the need of operative
delivery?
Strong local anasethetic solution with high
motor blockade compromises parturient’s
ability to actively push
