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.

1. COMPLICATIONS OF REGIONAL
TECHNIQUES IN OBSTETRICS
Dr.Sreejith.H

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

7. COMPLICATIONS RELATED TO
NEEDLE/CATHETER PLACEMENT
Trauma
 Backache
 Dural puncture/leak
 Postdural puncture headache
 Diplopia
 Tinnitus
Neural injury
 Nerve root damage
 Spinal cord damage
 Cauda equina syndrome
Bleeding
 Intraspinal/epidural hematoma

8. Misplacement
 No effect/inadequate anesthesia
 Subdural block
 Inadvertent subarachnoid block1
 Inadvertent intravascular injection
Catheter shearing/retention
Inflammation
 Arachnoiditis
Infection
 Meningitis
 Epidural abscess

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

18. DIFFERENTIAL DIAGNOSIS
 Eclampsia , migraine, tension headache ,
pneumocephalus
 Infections including sinusitis& meningitis
 Cortical vein thrombosis & saggital sinus
thrombosis
 Hypertensive encephalopathy
 Subdural haematoma

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

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

26. INADEQUATE ANALGESIA
 Failure rate of epidural analgesia ranges
from 1.5% to 5 % depending on the skill of
the anaesthetist

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