Page 50 - Part 2 Anesthesiology Common Risk Issues

SVMIC Anesthesiology: Common Risk Issues

necessary. The need for effective pain management does not

necessarily stop with the delivery of the baby. Once a baby is
born, the uterus continues to contract, which forces the placenta

to separate from the wall of the uterus. The placenta is then
delivered by the mother, and is often referred the third stage

of labor. If the placenta is retained and cannot be delivered
naturally, anesthesia is normally used to lessen the pain. In

general, there is no preferred anesthetic technique for removal
of retained placenta. If an epidural catheter is in place and the

patient is stable, consider providing epidural anesthesia; but the
hemodynamic status of the patient must be assessed before

administering neuraxial anesthesia. If additional anesthesia is
mandated for the delivery of the placenta, the anesthesiologist

should consider aspiration prophylaxis, and sedation/analgesia
should be carefully titrated due to the potential risks of

respiratory depression and pulmonary aspiration during the
immediate postpartum period.

In cases involving major maternal hemorrhage with

hemodynamic instability, general anesthesia with an
endotracheal tube may be considered in preference to neuraxial

anesthesia. When the obstetrician determines that removal of
the retained placental tissue is mandated, nitroglycerin may be

used for uterine relaxation during removal of retained placental
tissue. Initiating treatment with incremental doses of IV or

sublingual (i.e., tablet or metered dose spray) may sufficiently
relax the uterus. In some cases with pregnant patients, a

vaginal delivery is not the best option, and a cesarean delivery
is scheduled. In other patients, for many and varied reasons,

an emergency cesarean is needed. The ASA requires that
equipment, facilities, and support personnel available in the

labor and delivery operating suite be comparable to those

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