Evidence-based Obstetric Anesthesia

256 Pages·2005·2.98 MB·English

Evidence-based
Obstetric Anesthesia
To my wife Janice and our sons Zvi, Moshe and Yoni – SHH
To Bill, Matthew and Mark – MJD
Evidence-based
Obstetric Anesthesia
Edited by
Stephen H. Halpern
Director of Obstetrical Anaesthesia
Sunnybrook and Women’s College Health Sciences Centre
University of Toronto
Toronto
Ontario
Canada
M. Joanne Douglas
Clinical Professor
Department of Anaesthesia
University of British Columbia and British Columbia’s Women’s Hospital
Vancouver
British Columbia
Canada
© 2005 by Blackwell Publishing Ltd
BMJ Books is an imprint of the BMJ Publishing Group Limited, used under licence
Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA
Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK
Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia
The right of the Authors to be identified as the Authors of this Work has been asserted
in accordance with the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system, or transmitted, in any form or by any means, electronic, mechanical,
photocopying, recording or otherwise, except as permitted by the UK Copyright,
Designs and Patents Act 1988, without the prior permission of the publisher.
First published 2005
Library of Congress Cataloging-in-Publication Data
Evidence-based obstetric anesthesia / edited by Stephen H. Halpern, M.
Joanne Douglas.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-7279-1734-8
ISBN-10: 0-7279-1734-X
1. Anesthesia in obstetrics. 2. Evidence-based medicine.
[DNLM: 1. Anesthesia, Obstetrical. 2. Evidence-Based Medicine.
I. Halpern, Stephen H. II. Douglas, M. Joanne.
RG732.E975 2005
617.9′682—dc22
2004028825
ISBN-13: 978-0-7279-1734-8
ISBN-10: 0-7279-1734-X
A catalogue record for this title is available from the British Library
Set in 9.5/12pt by Graphicraft Limited, Hong Kong
Printed and bound in India by Gopsons Papers Ltd, Noida
Commissioning Editor: Mary Banks
Project Manager: Alice Nelson
Development Editor: Nick Morgan
Production Controller: Kate Charman
For further information on Blackwell Publishing, visit our website:
http://www.blackwellpublishing.com
The publisher’s policy is to use permanent paper from mills that operate a sustainable
forestry policy, and which has been manufactured from pulp processed using acid-free
and elementary chlorine-free practices. Furthermore, the publisher ensures that the text
paper and cover board used have met acceptable environmental accreditation standards.
Contents
Contributors, vii Part 2: Anesthesia for cesarean
section, 87
Preface, ix
9 The effect of increasing central blood volume to
Acknowledgments, xi
decrease the incidence of hypotension following
spinal anesthesia for cesarean section, 89
Part 1: Analgesia for normal labor, 1 Pamela J. Morgan
1 Consent for obstetric analgesia and 10 The use of vasopressors for the prevention and
anesthesia, 3 treatment of hypotension secondary to
M. Joanne Douglas regional anesthesia for cesarean section, 101
2 Epidural analgesia and the progress Stephen H. Halpern & Michelle Chochinov
of labor, 10 11 Is regional anesthesia safer than general anesthesia
Barbara L. Leighton & Stephen H. Halpern for cesarean section?, 108
3 Maintenance of epidural analgesia for labor – Yehuda Ginosar, Ian F. Russell & Stephen H.
continuous infusion or patient controlled, 23 Halpern
Stephen H. Halpern
12 Prevention and treatment of side-effects of
4 The use of transcutaneous electrical nerve neuraxial opioids, 132
stimulation for labor pain, 30 Niall L. Purdie & Martin van der Vyver
Carolyn F. Weiniger
13 Multimodal analgesia following cesarean section:
5 Is nitrous oxide an effective analgesic for labor? Use of non-steroidal anti-inflammatory drugs
A qualitative systematic review, 38 combined with neuraxial opioids, 152
Jean E. Kronberg & Dorothy E.A. Thompson Pamela Angle & Kamal Hussain
6 Choice of local anesthetic for labor and
delivery– bupivacaine, ropivacaine and Part 3: Complications of obstetric
levobupivacaine, 56 anesthesia, 163
Stephen H. Halpern
14 The use of neuraxial anesthesia in parturients with
7 Intrathecal opioids in labor– do they increase the thrombocytopenia: What is an adequate platelet
risk of fetal bradycardia?, 68 count?, 165
Chahé Mardirosoff & Martin R. Tramèr M. Joanne Douglas
8 Epidural catheter design and the incidence of 15 A rational approach to aspiration prophylaxis, 178
complications, 77 Geraldine O’Sullivan, Darren Hart & Andrew
Margaret Srebrnjak & Stephen H. Halpern Shennan
v
Contents
16 Postdural puncture headache, 192 19 Is there a difference between the obstetric and
Peter T-L. Choi & Stefan Lucas non-obstetric airway?, 225
Eric Goldszmidt
17 Epidural analgesia and back pain, 208
Terrance W. Breen Appendix: Jadad scale for reporting randomized
controlled trials, 237
18 Analgesia for external cephalic version, 217
William Wight Index, 239
vi
Contributors
Pamela Angle MD, FRCP(C) Stephen H. Halpern MD, MSc, FRCP(C)
Assistant Professor, Dept of Anaesthesia, Sunnybrook and Director of Obstetrical Anaesthesia, Sunnybrook and
Women’s College Health Sciences Centre, University of Women’s College Health Sciences Centre, University of
Toronto, 76 Grenville St, Toronto, Ontario M5S 1B2, Toronto, 76 Grenville St, Toronto, Ontario M5S 1B2,
Canada Canada
Terrance W. Breen MD Darren Hart RM
Dept of Anesthesiology, Duke University Medical Center
Research Midwife, Dept of Obstetrics and Gynaecology,
3094, Durham, NC 27710, USA
Guy’s and St Thomas’ Hospital, London SE1 7EH, UK
Michelle Chochinov MD, FRCP(C)
Kamal Hussain MB BS, FFARSCI
Dept of Anaesthesia, Sunnybrook and Women’s
Obstetric Anaesthesia Fellow, Dept of Anaesthesia,
College Health Sciences Centre, University of Toronto,
Sunnybrook and Women’s College Health Sciences Centre,
2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada
University of Toronto, 76 Grenville St, Toronto, Ontario
M5S 1B2, Canada
Peter T-L. Choi MD, MSc, FRCP(C)
Assistant Professor, Dept of Anaesthesia, University of
Jean E. Kronberg PhD, MD, FRCP(C)
British Columbia, 910 West Tenth Ave, Vancouver, British
Columbia V5Z 4E3, Canada Associate Professor, Dept of Anaesthesia, University of
Toronto and Active Staff, Sunnybrook and Women’s
M. Joanne Douglas MD, FRCP(C) College Health Sciences Centre, University of Toronto,
76 Grenville St, Toronto, Ontario M5S 1B2, Canada
Clinical Professor, Dept of Anaesthesia, Faculty of Medicine,
University of British Columbia and British Columbia’s
Women’s Hospital, 4500 Oak St, Vancouver, British Barbara L. Leighton MD
Columbia V6H 3N1, Canada Dept of Anesthesiology, Washington University, Campus
Box 8054, 660 S. Euclid Ave, St Louis, MO 63110-1093,
Yehuda Ginosar BSc, MB BS USA
Lecturer in Anesthesiology, Hebrew University Medical
School, Jerusalem, Israel, and Senior Anesthesiologist, Dept
Stefan Lucas MD
of Anesthesiology and Critical Care Medicine, Hadassah
University of Rochester, School of Medicine and Dentistry,
Hebrew University Medical Center, POB 12000, Jerusalem
Dept of Anesthesiology, 601 Elmwood Avenue, Rochester,
91120, Israel
NY 14642, USA
Eric Goldszmidt MD, FRCP(C)
Dept of Anaesthesia, Mount Sinai Hospital and University of Chahé Mardirosoff MD
Toronto, 600 University Ave, Toronto, Ontario M5G 1X5, Service d’Anesthésie et Réanimation, Polyclinique de Savoie,
Canada 8, rue F. David, 74100 Annemasse, France
vii
Contributors
Pamela J. Morgan MD, CCFP, FRCP(C) Margaret Srebrnjak BSc, MD, FRCP(C)
Associate Professor, Staff Anaesthesiologist, Sunnybrook Dept of Anaesthesia, Sunnybrook and Women’s College
and Women’s College Health Sciences Centre, University Health Sciences Centre, University of Toronto, 76 Grenville
ofToronto, 76 Grenville St, Toronto, Ontario M5S 1B2, St, Toronto, Ontario M5S 1B2, Canada
Canada
Dorothy E.A. ThompsonMB ChB, FRCP(C)
Geraldine O’Sullivan MD, FRCA Honorary Staff, Dept of Anaesthesia, Sunnybrook and
Dept of Anaesthetics, Guy’s and St Thomas’ Hospital, Women’s College Health Sciences Centre, University of
London SE1 7EH, UK Toronto, 76 Grenville St, Toronto, Ontario M5S 1B2,
Canada
Niall L. Purdie MB ChB, FFARCSI
Dept of Anaesthesia, Sunnybrook and Women’s Martin R. Tramèr MD, DPhil
College Health Sciences Centre, University of Toronto, Consultant Anesthetist, Division of Anesthesiology, Geneva
76 Grenville St, Toronto, Ontario M5S 1B2, Canada University Hospitals, CH-1211 Geneva, Switzerland
Ian F. Russell MB ChB, FRCA Martin van der VyverMB ChB, MMed(Anes),
Honorary Senior Lecturer, Academic Dept of Obstetrics and FCA(SA)
Gynaecology, Hull University, and Consultant Anaesthetist, Sunnybrook and Women’s College Health Sciences Centre,
Dept of Anaesthesia, Hull Royal Infirmary, Anlaby Road, University of Toronto, 76 Grenville St, Toronto, Ontario
Hull HU3 2JZ, UK M5S 1B2, Canada
Andrew Shennan MD, MRCOG Carolyn F. Weiniger MB ChB
Senior Lecturer in Obstetrics and Gynaecology, Dept of Dept of Anesthesia, Hadassah University Hospital, POB
Obstetrics and Gynaecology, Guy’s and St Thomas’ 12000, Jerusalem 91120, Israel
Hospital, London SE1 7EH, UK
William Wight MB BS, FRCA
Consultant Anaesthetist, Dept of Anaesthesia, Royal Victoria
Infirmary, Newcastle upon Tyne NE1 4LP, UK
viii
Preface
Since the introduction of anesthesia to obstetric prac- The contributors were asked to write each chapter
tice by James Young Simpson in 1847, there have been in the form of a systematic review. Rather than provid-
controversies concerning its use. In addition to the ing a general discussion, each chapter was designed to
larger issue of any medical intervention during normal answer one or more discrete clinical questions. The
childbirth, the lay public and medical community have basis of each chapter is an extensive literature review
struggled with the balance between the benefits and for each topic for the best evidence. In an effort to
the risks of analgesia and anesthesia to the mother and reduce bias, most of the information presented comes
fetus during labor and delivery. These controversies from randomized controlled trials or high-quality
persist despite numerous advances in our knowledge cohort studies. This type of data does not exist for top-
about the physiology and pharmacology related to ics that deal with rare events such as maternal mortal-
pregnancy and childbirth. ity, aspiration pneumonitis and epidural hematoma.
Compared to other fields in medicine, many of the The contributors of chapters on these topics relied on
issues in obstetric anesthesia can be difficult to study. data from national surveys and other databases for
This is because the obstetric anesthesiologist often sees some of the information.
the patient for the first time under emotionally and The contributors then summarized the data. In
physically stressful circumstances. While some of the most cases this was done qualitatively through the
early animal studies were helpful in delineating the extensive use of data tables. In some cases, a formal
physiology of pregnancy, this information was accepted meta-analysis could be performed. Finally, each con-
as dogma and applied, sometimes inappropriately, to tributor interpreted the existing data to answer the
humans. Even the results of some of the older human clinical questions originally posed. Thus, the informa-
studies were more likely to reflect the biases of the tion on each topic is meant to be complete, accurate
researchers than the “truth.” Many of these early stud- and accessible to clinicians. In some areas, there
ies have not been repeated but a growing body of high are obvious gaps in our knowledge and these are
quality research in the field of obstetric anesthesia has highlighted.
been published in the last 20 years. The book is divided into three main sections. The
The purpose of this book is to identify and synthes- first deals with analgesia for labor, which is probably
ize the strongest research in obstetric anesthesia in the most controversial area related to obstetric anes-
order to promote best practice. There are many areas thesia. This includes chapters about informed consent,
that will not be found in this volume because of the new techniques (patient-controlled epidural analgesia,
absence of sound research on the subject. Most of the combined spinal epidural analgesia), new drugs (ropi-
topics were chosen because they were of interest to vacaine, levobupivacaine) and controversies about
clinicians and/or there was extensive, rigorous research equipment (epidural catheters). The efficacy of nitrous
on the subject matter. Perhaps in the future, as more oxide is discussed in light of information that has
research becomes available, other topics will be added. rarely been presented previously. Finally, there is a
ix
Preface
brief, but thorough, examination of the use of TENS This book is intended for the use of all clinicians
for labor analgesia. who practice obstetric anesthesia. Trainees at all levels
The second section – Anesthesia for cesarean sec- can benefit both from the content and the approach
tion – contains two chapters on the prevention to clinical problems. Rather than taking the words
and treatment of hypotension associated with spinal of their mentors at face value, we would encourage
anesthesia. One discusses which fluids are best, the them to ask “how do you know that?” or seek the best
other which vasopressor. Following these chapters is a evidence themselves.
discussion on the treatment of postoperative pain and As more research is being performed and published
the side-effects resulting from that treatment. Finally, the conclusions drawn from this current literature
the assumption that “regional anesthesia is good and review may change. Hopefully, this book will stimulate
general anesthesia is bad” is discussed in some detail. further research leading to a clearer understanding as
The third and final section – Complications of to the role of obstetric anesthesia in pregnancy and
obstetric anesthesia – contains a number of contro- childbirth.
versial topics. Should the parturient with a low platelet We would like to take this opportunity to thank
count be offered epidural analgesia? Does epidural the contributors to the book for doing such a thorough
analgesia cause long-term back pain? Is the airway job researching their topics and presenting it in a man-
of the parturient really different from non-pregnant ner that, hopefully, clinicians and students will find
patients? Other topics presented in this section include useful.
the issue of postdural puncture headache in the par-
SHH
turient and analgesia for external cephalic version.
MJD
x