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A 34-year-old woman, G3P2, is seen in consultation by the Obstetric Anesthesia Service at 32 weeks estimated gestational age (EGA) prior to planned cesarean hysterectomy at 34 weeks EGA for placenta previa and accreta (L-1). The placenta appears to be invading the patient’s bladder, right rectus abdominis muscle, and possibly the colon. In general, the patient is in excellent health (L-2) and her two prior cesarean deliveries were performed under spinal anesthesia with no difficulties and with excellent postoperative pain control from neuraxial opioids.

The performance of non-obstetric intra-abdominal surgery during pregnancy is a delicate balancing act requiring a multidisciplinary team. The primary goal of such surgery should always include attainment and retention of current and future maternal and neonatal safety. Diverse considerations must be entertained when discussing non-obstetric surgery during pregnancy given the “two patients in one” scenario. Major advances that have occurred in recent years in diagnostic imaging, obstetric anesthesia, and surgical techniques may influence these deliberations. The following chapter addresses many of the diagnostic and management dilemmas likely to be encountered when non-obstetric intra-abdominal surgery is being deliberated or performed.

Obesity affects nearly 40% of the reproductive-age population and is associated with comorbid conditions that can hinder reproduction. Not only does obesity decrease fertility, once conception is achieved, women with obesity have been noted to have increased complication rates compared to their normal body mass index (BMI) counterparts. With the increasing number of women of childbearing age with a history of bariatric surgery, the benefits and risks of weight loss surgery on maternal and fetal outcomes are important to understand. Some of the benefits experienced after bariatric surgery in this regard include increased fertility for both men and women and decreased rates of preeclampsia, gestational diabetes, cesarean section, and macrosomia. The risks include small-for-gestational age neonates, especially if conception occurs within first 2 years after bariatric surgery, and internal hernia. Overall, bariatric surgery improves pregnancy outcomes in patients with obesity.

This chapter discusses the various oxytocic drugs utilized during obstetric anesthesia. It discusses the indications and contraindications for each medication, as well as their side effects.

Abuse of legal and illegal substances during pregnancy presents management challenges to both obstetricians and anesthesiologists. Obstetric and neonatal outcomes are adversely affected in most parturients who abuse drugs. Antepartum maternal and fetal surveillance is increased over that in nonsubstance abusing women. While peripartum obstetric management is typically not changed, anesthetic management is often affected by alterations in anesthetic drug requirements and abnormal maternal hemodynamic responses to their administration. Post-delivery pain management is often challenging.

The increasing number of women with perinatal mental illness has been requiring obstetric anesthesia care. These disorders include mood, anxiety, psychotic, substance use, eating, and personality disorders. Preoperative evaluation of the patients with known or suspected psychiatric disease should be adjusted according to the type and severity of the mental disorder. The patients with stable mental status should be encouraged to have regional anesthesia due to well-known benefits of techniques during obstetric anesthesia. Yet, the choice of anesthetic technique should actively be depended on the mental status of the patient, and postoperative care should be attentively managed regarding pain relief and continuation of medical therapy for the psychiatric disease. The purpose of this chapter is to summarize perinatal psychiatric illnesses and to detail their implications on obstetric anesthesia regarding the main issues mentioned above.

Stimulant abuse, particularly methamphetamine, increased dramatically among women of childbearing age between 1994 and 2006; however, the rate of abuse has plateaued since and use during pregnancy is difficult to estimate. Maternal physiologic effects are similar to that of cocaine, with sympathetic system activation during periods of acute intoxication and significant psychosis with long-term use. Poorer obstetric and neonatal outcomes to include preterm delivery, placental abruption, and small for gestational age deliveries occur; however, long-term child outcomes appear similar to that of non-stimulant-abusing women. Intra- and postpartum obstetric management are similar to that of the cocaine-abusing mother. Neuraxial blockade may be complicated by more frequent and more difficult to treat hypotension due to catecholamine depletion in the chronic non-intoxicated abuser.

Alcohol is the most commonly abused substance during pregnancy. Heavy maternal ingestion causes fetal anomalies and can lead to fetal alcohol syndrome, characterized by impairments in neurobehavioral and physical development. All pregnant women should be screened for heavy alcohol use. Therapy to prevent alcohol withdrawal is required, although obstetric management differs little than that of the nonalcoholic parturient. Altered responses to anesthetic drugs can be anticipated.

Asthma is a common respiratory disorder encountered in pregnant patients. Its management requires continuation of medication, careful evaluation, optimization prior to labor, and prompt recognition of exacerbations. This necessitates teamwork between pulmonary disease specialist, obstetrician, and anesthesiologist. Regional analgesia and anesthesia is preferred over airway instrumentation.

Obstetric anesthesia providers most commonly provide either labor analgesia or cesarean delivery anesthesia, though there are a number of other obstetric procedures that also require anesthesia care. This chapter highlights the surgical and anesthetic considerations of the most common non-delivery obstetric procedures, including: postpartum tubal sterilization, external cephalic version, cerclage, dilation and curettage or evacuation, and minimally invasive fetal procedures.

Ex Utero Intrapartum Treatment (EXIT) are therapeutic interventions that are part of an extended cesarean section for fetuses with a variety of life-threatening airway abnormalities or congenital malformations. The anesthetic goals are to maintain the integrity of the maternal-fetal circulation while maintaining optimal uterine relaxation, the physiology and anesthetic goal of the EXIT procedure are reviewed and modifications to the classic treatment discussed. Multidisciplinary collaboration is required for optimum results.

Regional anesthesia is a safe, effective, and widely used modality for caesarean section delivery. In addition it is useful for controlling labor pain and postoperative pain. While severe complications are rare, common complications, such as hypotension, must be considered when using neuraxial anesthesia. Hypotension occurs in around half of individuals receiving central neuraxial block; coloading with crystalloid is a common method to prevent hypotension. Administration of vasopressors may be required to stabilize blood pressure. Local anesthetic toxicity is a potential complication, given the abundant vascularity of the epidural space; this presents concern for both parturient and fetus. Treating every epidural dose as a test dose can help avoid infusion of toxic doses. Paracervical and pudendal blocks are decreasing in popularity due to inadequate pain control and associated complications. Other complications to be considered in the obstetric population include neurologic dysfunction, infection, chronic adhesive arachnoiditis, postdural puncture headache, cauda equina lesion, damage to the spinal cord, transient neurologic symptoms, inadequate/extensive block, and rarely, respiratory and cardiac arrest.

Obstetric anesthesia care is generally considered to be one of the higher risk areas of regional and general anesthetic techniques, although it is extremely safe and widely used. It is reassuring that serious complications related to central neuraxial block are uncommon, and they have to grapple with issues related to anatomic-physiologic changes in pregnancy and various other factors, including increasing trend of cesarean section, advanced maternal age, obesity, and other concomitant medical diseases. This chapter highlights the management and therapy of following regional anesthesia-related complications encountered during the obstetric regional anesthesia practice: cardiovascular, infective, hematologic, post-dural puncture headache, and neurologic complications.

A healthy 25-year-old G3P2002 patient at 38-week gestation was referred to the high-risk obstetric anesthesia service due to the presence of abnormal placentation. Her past surgical history included 2 previous cesarean deliveries. The ultrasound examination was suspicious for a complete anterior placenta previa with multiple placental lakes, which looked even more likely after magnetic resonance imaging (MRI).

A 32-year-old woman, G3P2, at 38-week gestation presented to triage with vaginal bleeding. She had two previous cesarean sections: the first for breech presentation and the second at her request, both of which were complicated by uterine atony and postpartum hemorrhage. She received a blood transfusion, but did not recall the amount or type of blood products administered.

I was not thrilled when the newest patient requested an epidural at the end of my shift on the obstetrics floor. To put it nicely, her anatomy promised it would be a technically challenging procedure—there were no palpable landmarks to speak of on her back. After my Tuohy needle hit bone for a fifth time, I called the supervising anesthesiologist covering obstetric anesthesia that day to provide assistance and moral support. He struggled for several minutes before his needle seemed to find a promising spot. And as he advanced the needle a touch more, his persistence was rewarded with a steady stream of cerebrospinal fluid. A “wet tap”—the attending and I stared at each other. He quickly removed the epidural catheter from the tray and threaded it through the needle into the intrathecal space.

Within surgical disciplines, obstetrics and anesthesia carry a greater risk of medicolegal liability although with improved monitoring and practice standards issued by national scientific societies such as the American College of Obstetricians and Gynecologists (ACOG) and the American Society of Anesthesiologists (ASA). Pain relief is becoming an area of concern. Analgesia refers to the relief of pain without the loss of consciousness. Modalities of analgesia during childbirth include regional analgesia, systemic opioid analgesia, continuous labor support, pudendal blocks, immersion in water during the first stage of labor, sterile water injections in the lumbosacral spine, hypnosis, and acupuncture [1]. Even though there are multiple options for labor pain management, women often experience pain during childbirth in accordance with their expectations. The ASA Closed Claims database [2] has shown that since the1990s the proportion of claims associated with general anesthesia has progressively declined while the proportion associated with regional analgesia has steadily increased although the majority of maternal injuries are minor (e.g., headache, back pain, pain during analgesia, neuropsychological consequences). In addition, [3] it reported that postnatal depression may be more common when analgesia is not used and pain during labor has been correlated with the development of posttraumatic stress disorder. Furthermore, men are also affected by severe labor pain. A survey of first-time fathers showed that the men whose partners received an epidural felt three times as helpful and involved during labor and delivery and had less anxiety and stress, as compared with men whose partners did not receive an epidural [3]. All these situations may reflect unrealistic expectations and dissatisfaction with parturient care, and litigation serves the purpose not only of reparation of injury and deterrence of standard of care but also of emotional vindication. This is especially true in Italy where labor analgesia is becoming an important public health issue with its introduction free of charge in SSN as LEA (Essential Levels of Assistance) (DPCM April 23, 2008, art. 37) but, at the same time, it is not performed in all hospitals [4] due to lack of funding. The problem is clear. Labor analgesia has to be considered an important aspect of the obstetric anesthesia practice, and the provision of adequate pain relief and management has foundation in the law of negligence. The law of medical negligence emphasizes taking reasonable care in all aspects of patient management and, with respect to this particular issue, doctors (the anesthetist as well as the obstetrician, midwife, neonatologist, and labor and delivery nurses) may breach their standard of care by failing to exchange information with the parturient and also with other members of the woman’s family as well as with the obstetric team; by failing to provide appropriate prenatal education and to acquire informed consent; by treating the pain inadequately or by failing to counteract adverse reaction and eventually perform acute resuscitation.