Skip to main content
SpringerLink
Log in

Neues aus der geburtshilflichen Anästhesie

New aspects of obstetric anesthesia

  • Leitthema
  • Published:
Der Anaesthesist Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Das Risikoprofil der Patientinnen hat sich in der geburtshilflichen Anästhesie wesentlich verändert. Noch mehr als bei anderen Disziplinen lebt gerade die geburtshilfliche Anästhesie daher im wahrsten Sinne des Worts von der engen Abstimmung aller Beteiligten und einer guten interdisziplinären Zusammenarbeit.

Ziel der Arbeit

Der Beitrag klärt über wichtige anästhesiologische Risiken im Rahmen der Geburt auf und vermittelt entsprechende Konzepte zur Prävention, Diagnose und zum Management peripartaler Komplikationen.

Material und Methode

Die Steigerung von Risikoschwangerschaften, die zu einem großen Teil auf eine Zunahme der Adipositas zurückzuführen ist, verlangt nach klar definierten Richtlinien und interdisziplinären Konzepten, die im vorliegenden Beitrag beschrieben und diskutiert werden. Die neuroaxiale Blockade ist weiterhin das wirksamste Verfahren zur Behandlung des Geburtsschmerzes und bietet mit den im Beitrag vorgestellten programmierten intermittierenden epiduralen Boli einen vielversprechenden neuen Modus. Schlussendlich haben die deutschsprachigen Länder Deutschland, Österreich, Schweiz einen Behandlungsalgorithmus für die postpartale Blutung entwickelt, der erläutert wird.

Ergebnisse

Die anästhesiologischen Komponenten einer Risikoschwangerschaft müssen frühzeitig erkannt werden; hierzu gehören u. a. Adipositas, Präeklampsie oder medikamentös-induzierte Koagulopathie. Die Epiduralanalgesie ist das effektivste Analgesieverfahren in der Geburtshilfe. Die patientinnengesteuerte Remifentanilanalgesie stellt – bei Kontraindikationen für ein neuroaxiales Verfahren – aktuell die beste Alternative dar.

Schlussfolgerung

In Risikosituationen, wie bei (Prä-)Eklampsie, notfallmäßiger Sectio caesarea, massiven Blutverlusten oder anderen intrapartalen Notfallsituationen ist die optimale interdisziplinäre Zusammenarbeit zwischen Hebammen, Geburtshelfern und Anästhesisten gefragt. Es sind jedoch nicht nur Notfallsituationen, die eine gute interdisziplinäre Zusammenarbeit erfordern; genauso wichtig ist die Zusammenarbeit im Erkennen von Risikoschwangerschaften und einer frühzeitigen gemeinsamen Planung der bevorstehenden Geburt.

Abstract

Background

The risk profile of patients in obstetric anesthesia has substantially changed. Even more so than other disciplines, obstetric anesthesia is therefore in the true sense of the word dependent on the close coordination of all concerned and a good interdisciplinary cooperation.

Aim

This article explains the important anesthesiological risks connected with parturition and presents the corresponding concepts for prevention, diagnosis and management of peripartum complications.

Material and methods

The increase in the number of high risk pregnancies, which are mostly due to an increase in obesity, require clearly defined guidelines and interdisciplinary concepts which are described and discussed in this article. The neuraxial block is still the most effective procedure for treatment of birth pain and offers a promising new method with the programmed intermittent epidural boluses presented in this article. Finally, the German speaking countries Germany, Austria and Switzerland have developed a treatment algorithm for the management of postpartum hemorrhage which is presented here.

Results

The anesthesiological components of a risk pregnancy must be recognized early and include obesity, preeclampsia and drug-induced coagulopathy. Epidural analgesia is the most effective analgesic procedure in obstetrics. Patient-controlled remifentanil analgesia currently represents the best alternative in cases of contraindications for a neuraxial procedure.

Conclusion

In risk situations, such as pre(eclempsia), emergency cesarean section, massive blood loss or other peripartum emergency situations, optimal interdisciplinary cooperation between midwives, obstetricians and anesthetists is required. However, not only emergency situations require a good interdisciplinary cooperation. Just as important is the cooperation to recognize risk pregnancies and a timely joint planning of the approaching birth.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1

Literatur

  1. Baron CM, Girling LG, Mathieson AL et al (2010) Obstetrical and neonatal outcomes in obese parturients. J Matern Fetal Neonatal Med 23:906–913

    Article  PubMed  Google Scholar 

  2.  Centre for Maternal and Child Enquiries (CMACE) (2010) Maternal obesity in the UK: findings from a national project. CMACE, London

  3.  The American College of Obstetricians and Gynecologists (2013) ACOG Committee opinion no. 548: weight gain during pregnancy. Obstet Gynecol 121:210–212

    Google Scholar 

  4. Fitzsimons KJ, Modder J (2011) Setting maternity care standards for women with obesity in pregnancy. Semin Fetal Neonatal Med 15:100–107

    Article  Google Scholar 

  5. Knight M, Kurinczuk JJ, Spark P et al (2010) Extreme obesity in pregnancy in the United Kingdom. Obstet Gynecol 115:989–997

    Article  PubMed  Google Scholar 

  6. Lucas DN (2010) The 30 minute decision to delivery time is unrealistic in morbidly obese women. Int J Obstet Anesth 19:431–435

    Article  CAS  PubMed  Google Scholar 

  7. Soens MA, Birnbach DJ, Ranasinghe JS, Zundert A van (2008) Obstetric anesthesia for the obese and morbidly obese patient: an ounce of prevention is worth more than a pound of treatment. Acta Anaesthesiol Scand 52:6–19

    Article  PubMed  Google Scholar 

  8. Carvalho B, Collins J, Drover DR et al (2011) ED50 and ED95 of intrathecal bupivacaine in morbidly obese patients undergoing cesarean delivery. Anesthesiology 114:529–535

    Article  CAS  PubMed  Google Scholar 

  9. Solomon C, Collis RE, Collins PW (2012) Haemostatic monitoring during postpartum haemorrhage and implications for management. Br J Anaesth 109:851–863

    Article  CAS  PubMed  Google Scholar 

  10. Anim-Somuah M, Smyth RM, Jones L (2011) Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev CD000331

  11. Zhang J, Landy HJ, Branch DW et al (2010) Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol 116:1281–1287

    Article  PubMed Central  PubMed  Google Scholar 

  12. Harper LM, Caughey AB, Odibo AO et al (2012) Normal progress of induced labor. Obstet Gynecol 119:1113–1118

    Article  PubMed  Google Scholar 

  13. Dennis AT, Castro J, Carr C et al (2012) Haemodynamics in women with untreated pre-eclampsia. Anaesthesia 67:1105–1118

    Article  CAS  PubMed  Google Scholar 

  14. Dyer RA, Piercy JL, Reed AR et al (2008) Hemodynamic changes associated with spinal anesthesia for cesarean delivery in severe preeclampsia. Anesthesiology 108:802–811

    Article  CAS  PubMed  Google Scholar 

  15. Centre for Maternal and Child Enquiries CMACE (2011) Saving mothers‘ lives: reviewing maternal deaths to make motherhood safer: 2006–08. The eighth report on confidential enquiries into maternal deaths in the United Kingdom. BJOG 118:1–203

    Google Scholar 

  16. Royal College of Obstetricians and Gynaecologists (2006) The management of severe pre-eclampsia/eclampsia. Guideline No. 10(A). RCOG press, London

  17. Dennis AT (2012) Management of pre-eclampsia: issues for anaesthetists. Anaesthesia 67:1009–1020

    Article  CAS  PubMed  Google Scholar 

  18. Gogarten W (2009) Preeclampsia and anaesthesia. Curr Opin Anaesthesiol 22:347–351

    Article  PubMed  Google Scholar 

  19. Fetsch NI, Bremerich DH (2008) Anästhesie bei Patientinnen mit Präeklampsie und Eklampsie. Anaesthesist 57:87–102

    Article  CAS  PubMed  Google Scholar 

  20. Martin JN, Thigpen BD, Moore RC et al (2005) Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol 105:246–254

    Article  PubMed  Google Scholar 

  21. Booth CMA, Buckley H, Wheatly S, Maguire S (2011) Attenuation of the hypertensive response to tracheal intubation in patients with severe preeclampsia: a UK postal survey. Int J Obstet Anesth 20:102–103

    Article  CAS  PubMed  Google Scholar 

  22. Park BY, Jeong CW, Jang EA et al (2011) Dose-related attenuation of cardiovascular responses to tracheal intubation by intravenous remifentanil bolus in severe pre-eclamptic patients undergoing Caesarean delivery. Br J Anaesth 106:82–87

    Article  CAS  PubMed  Google Scholar 

  23. Simmons SW, Taghizadeh N, Dennis AT et al (2012) Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database Syst Rev 10:CD003401

    PubMed  Google Scholar 

  24. Gogarten W, Van Aken H (2005) Regionalanästhesie in der Geburtshilfe – neue Entwicklungen. Zentralbl Gynakol 127:361–367

    Article  CAS  PubMed  Google Scholar 

  25. Weiniger CF, Yaghmour H, Nadjari M et al (2009) Walking reduces the post-void residual volume in parturients with epidural analgesia for labor: a randomized-controlled study. Acta Anaesthesiol Scand 53:665–672

    Article  CAS  PubMed  Google Scholar 

  26. Fegley AJ, Lerman J, Wissler R (2008) Epidural multiorifice catheters function as single-orifice catheters: an in vitro study. Anesth Analg 107:1079–1081

    Article  PubMed  Google Scholar 

  27. Halpern SH, Carvalho B (2009) Patient-controlled epidural analgesia for labor. Anesth Analg 108:921–928

    Article  CAS  PubMed  Google Scholar 

  28. Wong CA, McCarthy RJ, Hewlett B (2011) The effect of manipulation of the programmed intermittent bolus time interval and injection volume on total drug use for labor epidural analgesia. Anesth Analg 112:904–911

    Article  CAS  PubMed  Google Scholar 

  29. Capogna GG, Camorcia MM, Stirparo SS, Farcomeni AA (2011) Programmed intermittent epidural bolus versus continuous epidural infusion for labor analgesia: the effects on maternal motor function and labor outcome. A randomized double-blind study in nulliparous women. Anesth Analg 113:826–831

    PubMed  Google Scholar 

  30. Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) (2009) Durchführung von Analgesie- und Anästhesieverfahren in der Geburtshilfe. Anaesthesiol Intensivmed S490–S495

  31. Gardner IC, Kinsella SM (2005) Obstetric epidural test doses: a survey of UK practice. Int J Obstet Anesth 14:96–103

    Article  CAS  PubMed  Google Scholar 

  32. Marcus HE, Behrend A, Schier R et al (2011) Anästhesiologisches Management der Sectio caesarea: Deutschlandweite Umfrage. Anaesthesist 60:916–928

    Article  CAS  PubMed  Google Scholar 

  33. Pratt S, Hess P, Vasudevan A (2013) A prospective randomized trial of lidocaine 30 mg versus 45 mg for epidural test dose for intrathecal injection in the obstetric population. Anesth Analg 116:125–132

    Article  CAS  PubMed  Google Scholar 

  34. Russell IF (2012) A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour. Int J Obstet Anesth 21:7–16

    Article  CAS  PubMed  Google Scholar 

  35. Angle P, Thompson D, Halpern S, Wilson DB (1999) Second stage pushing correlates with headache after unintentional dural puncture in parturients. Can J Anaesth 46:861–866

    Article  CAS  PubMed  Google Scholar 

  36. Van de Velde M, Schepers R, Berends N et al (2008) Ten years of experience with accidental dural puncture and post-dural puncture headache in a tertiary obstetric anaesthesia department. Int J Obstet Anesth 17:329–335

    Article  Google Scholar 

  37. Apfel CC, Saxena A, Cakmakkaya OS et al (2010) Prevention of postdural puncture headache after accidental dural puncture: a quantitative systematic review. Br J Anaesth 105:255–263

    Article  CAS  PubMed  Google Scholar 

  38. Baysinger CL, Pope JE, Lockhart EM, Mercaldo ND (2011) The management of accidental dural puncture and postdural puncture headache: a North American survey. J Clin Anesth 23:349–360

    Article  PubMed  Google Scholar 

  39. Kleine-Brüggeney M, Kranke P, Stamer UM (2011) Prophylaxe und Therapie des postpunktionellen Kopfschmerzes. Anasthesiol Intensivmed Notfallmed Schmerzther 46:516–524

    Article  PubMed  Google Scholar 

  40. Paech MJ, Doherty DA, Christmas T et al (2011) The volume of blood for epidural blood patch in obstetrics: a randomized, blinded clinical trial. Anesth Analg 113:126–133

    Article  PubMed  Google Scholar 

  41. Price ML, Reynolds F, Morgan BM (1991) Extending epidural blockade for emergency caesarean section. Evaluation of 2 % lignocaine with adrenaline. Int J Obstet Anesth 1:13–18

    Article  CAS  PubMed  Google Scholar 

  42. Aiono-Le Tagaloa L, Butwick AJ, Carvalho B (2009) A survey of perioperative and postoperative anesthetic practices for cesarean delivery. Anesthesiol Res Pract 2009:510642

    Google Scholar 

  43. Hillyard SG, Bate TE, Corcoran TB et al (2011) Extending epidural analgesia for emergency Caesarean section: a meta-analysis. Br J Anaesth 107:668–678

    Article  CAS  PubMed  Google Scholar 

  44. Allam J, Malhotra S, Hemingway C, Yentis SM (2008) Epidural lidocaine-bicarbonate-adrenaline vs levobupivacaine for emergency Caesarean section: a randomised controlled trial. Anaesthesia 63:243–249

    Article  CAS  PubMed  Google Scholar 

  45. Bauer ME, Kountanis JA, Tsen LC et al (2012) Risk factors for failed conversion of labor epidural analgesia to cesarean delivery anesthesia: a systematic review and meta-analysis of observational trials. Int J Obstet Anesth 21:294–309

    Article  CAS  PubMed  Google Scholar 

  46. Evron S, Ezri T (2007) Options for systemic labor analgesia. Curr Opin Anaesthesiol 20:181–185

    Article  PubMed  Google Scholar 

  47. Hill D (2008) Remifentanil in obstetrics. Curr Opin Anaesthesiol 21:270–274

    Article  PubMed  Google Scholar 

  48. Hinova A, Fernando R (2009) Systemic remifentanil for labor analgesia. Anesth Analg 109:1925–1929

    Article  CAS  PubMed  Google Scholar 

  49. Schnabel AA, Hahn NN, Broscheit JJ et al (2012) Remifentanil for labour analgesia: a meta-analysis of randomised controlled trials. Eur J Anaesthesiol 29:177–185

    Article  CAS  PubMed  Google Scholar 

  50. Muchatuta NA, Kinsella SM (2013) Remifentanil for labour analgesia: time to draw breath? Anaesthesia 68:231–235

    Article  CAS  PubMed  Google Scholar 

  51. Klomp TT, Poppel MM van, Jones LL et al (2011) Inhaled analgesia for pain management in labour. Cochrane Database Syst Rev 9:CD009351–CD009351

    Google Scholar 

  52. Royal College of Obstetricians and Gynaecologists (2011) The use of antithrombotics in the prevention of recurrent pregnancy loss. Scientific Impact Paper 26. RCOG press, London

  53. Royal College of Obstetricians and Gynaecologists (2009) Reducing the risk of thrombosis and embolism during pregnancy and the puerperium. Green-top Guideline No. 37a. RCOG press, London

  54. Gogarten W, Vandermeulen E, Van Aken H et al (2010) Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol 27:999–1015

    Article  CAS  PubMed  Google Scholar 

Download references

Einhaltung ethischer Richtlinien

Interessenkonflikt. Thierry Girard, Stefan Brugger und Irene Hösli geben an, dass kein Interessenkonflikt besteht. Das vorliegende Manuskript enthält keine Studien an Menschen oder Tieren.

Author information

Authors and Affiliations

  1. Anästhesiologie, Universitätssital Basel, Spitalstr. 21, 4031, Basel, Schweiz

    T. Girard & S. Brugger

  2. Geburtshilfe und Schwangerschaftsmedizin, Frauenklinik, Universitätsspital Basel, Basel, Schweiz

    I. Hösli

Authors
  1. T. Girard
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. S. Brugger
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. I. Hösli
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to T. Girard.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Girard, T., Brugger, S. & Hösli, I. Neues aus der geburtshilflichen Anästhesie. Anaesthesist 62, 963–972 (2013). https://doi.org/10.1007/s00101-013-2235-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00101-013-2235-1

Schlüsselwörter

Keywords

Search

Navigation