Anatomy for anaesthesia, nerve supply of Uterus & Cervix

Anatomy of Uterus and Cervix, incuding the nerve supply.
Application for Anaesthesiology.

1. Anatomy for Anaesthesia, N erve supply of Uterus/ Cervix Dr Leena Tayshete 29-09-2014 1 Indraprastha Apollo Hospital, New Delhi

2. Uterus Pear shaped- 8 cm long, 5 cm wide. Supported by pelvic diaphragm. Parts- Fundus , Body, Isthmus, Cervix. Uterine walls- Perimetrium , Myometrium , Endometrium . Cervix 2.5 cm long. Internal Os- connects to uterus. External Os- connects to vagina. Parts- Supravaginal part ( anteriorly is bladder, posteriorly is the recto-uterine pouch). Vaginal part. 29-09-2014 2 Indraprastha Apollo Hospital, New Delhi

3. Vascular supply (uterus/ cervix) Arterial- Uterine arteries (branches of internal iliac arteries). Vaginal arteries (branches of uterine arteries with anastomoses with internal pudendal arteries ). Venous- Via uterine venous plexus to internal iliac veins. Lymphatics - External iliac nodes, Internal iliac & sacral nodes, Superficial inguinal nodes. 29-09-2014 3 Indraprastha Apollo Hospital, New Delhi

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5. Innervation (uterus/ cervix) T he uterovaginal plexus, subdivision of inferior hypogastric (pelvic) plexus. sympathetic , parasympathetic, and visceral afferents to and from the uterus. Sympathetic- lower lumbar spinal cord segments via lumbar splanchnic nerves and intermediate plexuses. Parasympathetic- pelvic splanchnic nerves ( S2,3,4) via pelvic plexus. Afferent- pain from body & fundus ascend through plexuses to lumbar splanchnic nerves  T10 to L1 . pain from cervix and all information (except pain from body and fundus )  parasympathetic fibers . 29-09-2014 5 Indraprastha Apollo Hospital, New Delhi

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7. Vagina 8 to 10 cm long. V aginal fornix- shallow   anterior , deep  posterior,  and  lateral fornices . Posterior fornix directly related to rectouterine pouch. Blood supply- Uterine arteries, Vaginal arteries, Middle rectal & internal pudendal arteries. Venous- Vaginal venous plexus  Uterine venous p lexus Internal iliac veins. 29-09-2014 7 Indraprastha Apollo Hospital, New Delhi

8. Innervation (vagina) Upper 3/4 th - same as uterus. Lower 1/4 th - Pudendal N. 29-09-2014 8 Indraprastha Apollo Hospital, New Delhi

9. Ligaments associated with uterus Broad ligament- Uterine arteries and veins run medially from the internal iliac arteries to the uterus at its base. Encloses the plexus of uterine veins. Ligament of the ovary- Round ligament of uterus- Crosses external iliac vessel to enter deep inguinal ring. Suspensory ligament of ovary- Covers the ovarian vessels, associated nerves, and lymphatics 29-09-2014 9 Indraprastha Apollo Hospital, New Delhi

10. Fallopian Tubes 10 cm long. Parts- Infundibulum , Ampulla , Isthmus, Uterine part. Blood supply- Anastomoses Uterine & Ovarian arteries. Venous- Uterine venous plexus, Ovarian veins. Lymphatics - Lumbar LN. Innervation - Ovarian and uterine plexuses (subdivision of lumbar plexus). 29-09-2014 10 Indraprastha Apollo Hospital, New Delhi

11. Ovaries 4cm long, 2 cm wide. In ovarian fossa ( lateral pelvic wall), between external and internal iliac vessels. Connected to lateral wall by suspensory ligaments of the ovary, containing ovarian vessels, nerves, and lymphatics . 29-09-2014 11 Indraprastha Apollo Hospital, New Delhi

12. Blood supply- Ovarian A. (br. of abdominal aorta). Venous- Pampiniform Plexus  Ovarian V. Rt Ovarian V- drains into IVC Lt Ovarian V- drains into Lt Renal V Lymphatics - lumbar LN Innervation - Sympathetic & afferent- along ovarian vessels. Parasympathetic- pelvic splanchnic nerves (S2,3,4) along ovarian vessels. 29-09-2014 12 Indraprastha Apollo Hospital, New Delhi

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14. Labour 29-09-2014 14 Indraprastha Apollo Hospital, New Delhi

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17. Physiology of labour pain Stage 1- (visceral afferent) Uterine contraction ( myometrial ischaemia - bradykinin , histamine, serotonin). Dilation of cervix, Distention of lower uterine segment. Paracervical & hypogastric plexus  lumbar sympathetic chain. Slow conducting visceral C fibres reaching T10- L1. Stage 2- (somatic) Distention of pelvic floor, vagina, perineum. Rapidly conducting A  fibres, S2- S4 ( Pudendal N). 29-09-2014 17 Indraprastha Apollo Hospital, New Delhi

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19. Types of Analgesia 29-09-2014 19 Indraprastha Apollo Hospital, New Delhi

20. Psychoprophylaxis teaching the mother conditioned reflexes to overcome the pain and fear of childbirth education program human support during labour breathing techniques relaxation techniques of voluntary muscles a strong focus of attention, and specific activities to concentrate on during contractions to block pain. 29-09-2014 Indraprastha Apollo Hospital, New Delhi 20

21. TENS (for early labour) Reduce pain by nociceptive inhibition at a presynaptic level in the dorsal horn by limiting central transmission. Electrical stimulation preferentially activates low-threshold myelinated nerves. Afferent inhibition-blocking impulses to target cells in the substantia gelatinosa of the dorsal horn. Enhance release of endorphins and dynorphins centrally. electrode pads over the lower back region in the distribution of T10-L1. 29-09-2014 Indraprastha Apollo Hospital, New Delhi 21

22. Inhaled Analgesia ENTONOX(50:50)- maximum analgesic effect after 45-60 seconds. Desflurane (0.2%). Enflurane . isoflurane (0.2% to 0.25%). Sevoflurane (0.8%). Drawback- drowsiness, unpleasant smell, cost, overdosage causing unconsciousness & loss of protective airway reflexes. 29-09-2014 Indraprastha Apollo Hospital, New Delhi 22

23. Parenteral Analgesics 29-09-2014 Indraprastha Apollo Hospital, New Delhi 23

24. Regional Analgesia / Anaesthesia Epidural Spinal CSE Continuous spinal Paracervical block Lumbar sympathetic block Pudendal block Perineal infiltration 29-09-2014 24 Indraprastha Apollo Hospital, New Delhi

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26. Epidural Analgesia T10-L1 sensory block during 1 st stage of labour. Further supplementation- late 1 st and 2 nd stage for sacral block. Advantages- pain relief without appreciable motor block, reduction in maternal catecholamines , rapidly achieve surgical anesthesia , extended for instrumental/ operative delivery, duration can be prolonged. 29-09-2014 Indraprastha Apollo Hospital, New Delhi 26

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28. Caudal Analgesia Relatively safe for perineal anaesthesia only, if volume limited to 10 ml, injected slowly (multiple aspirations). This dose is less than half that which is required to achieve full labour analgesia. Should be inserted before head is on the perineum. For perineal pain, labour pain, forceps delivery, manual removal of placenta. Less commonly- anaesthesia for artificial rupture of the membranes, suturing episiotomy & vaginal laceration. Complications- Vascular tap, failed block(8%), subarachnoid injection, infection, fetal injection. 29-09-2014 Indraprastha Apollo Hospital, New Delhi 28

29. Spinal Analgesia Very early labor , distressed parturient, instrumental deliveries. Consideration- displacement of CSF (enlarged epidural V, greater intra abdo pr.), lower CSF sp. gravity in pregnancy, softer ligamentum flavum (hormonal), difficulty flexion. 29-09-2014 Indraprastha Apollo Hospital, New Delhi 29

30. Continuous Spinal Analgesia Continuous spinal analgesia with a “ macrocatheter ” - cases of accidental dural puncture/ very high-risk parturients . Reduce the incidence of post– dural puncture headache (PDPH) after accidental dural puncture with epidural needle. Inform all personnel involved in the care of a parturient with a spinal catheter , to avoid accidental overdose of local anesthetic . 29-09-2014 Indraprastha Apollo Hospital, New Delhi 30

31. CSE Rapid-onset analgesia with minimal risk of toxicity or impaired motor block. Ability to prolong duration of analgesia. Because of the minimal motor block, termed “the walking epidural.” ?? Advantage- avoids incomplete blockade, motor block, and poor sacral spread of epidural technique. reduced duration of the first stage of labour in primiparous . 29-09-2014 Indraprastha Apollo Hospital, New Delhi 31

32. Paracervical block (1 st stage of labour) Upper agina , cervix, lower uterine segment pain (visceral afferent)  join sympathetic chain at L2-L3 & enter spinal cord at T10-L1. Block paracervical ganglion ( Frankenhauser’s ganglion) lat. & post. to cervico -uterine junction. 29-09-2014 32 Indraprastha Apollo Hospital, New Delhi

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34. Drug injected in Lt & Rt lat. fornix 4 o’clock & 8 o’clock position, depth 2-3 mm. 5-10 ml volume each side (wait 5-10 mins , observe fetal HR before injecting other side). Complication- Vasovagal syncope, laceration, LA tox , parametrial hematoma, postpartum neuropathy, paracervical / retropsoas / subgluteal abscess. Fetal scalp injection (when >8cm dilation)  fetal bradycardia . 29-09-2014 34 Indraprastha Apollo Hospital, New Delhi

35. Lumbar Sympathetic Block (1 st stage labour) Lower uterine & cervical visceral afferent sensory fibres join sympathetic chain at L2-L3. Advantage- accelerated labour. More rapid rate of cervical dilation in 1 st 2hours of analgesia ( bt no difference in rate of dilation during active phase of 1 st stage labour). Can be performed in cases of prev. back Sx . 29-09-2014 35 Indraprastha Apollo Hospital, New Delhi

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37. Technique- 10cm 22G needle. Identify L2 tranverse process  withdraw needle redirect  advanced 5cm. Tip ant. Lat. To vertebral column, just ant. to medial attachment of Psoas M. Drug injected in two 5ml increments. Complications- hypotension(5-15%), LA tox , total spinal, retroperitoneal hematoma, horner’s synd , PDPH. 29-09-2014 37 Indraprastha Apollo Hospital, New Delhi

38. Pudendal Nerve Block (2 nd stage labour) Ant primary div. of 2 nd , 3 rd & 4 th sacral nerves. Sensory- lower vagina, vulva, perineum. Motor- Perineal muscles, Ext. Anal sphincter. For- sopntaneous vaginal & outlet forceps delivery. Inadequate for- mid forceps delivery, post partum examination, repair of upper vagina & cervix, manual exploration of uterine cavity. 29-09-2014 38 Indraprastha Apollo Hospital, New Delhi

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40. Technique- Transvaginal / Transperineal . Needle- Iowa Trumpet/ Kobak . Needle to protrude 1-1.5cm beyond guide. Needle introduced through vaginal mucosa & sacrospinous ligament, just med. & post. to ischial spine. Drug vol - 7ml each side. Complication- laceration, LA toxicity, Vaginal/ ischiorectal /retroperitoneal hematoma, retropsoas / subgluteal abscess. 29-09-2014 40 Indraprastha Apollo Hospital, New Delhi

41. Perineal Infiltration Application- Failure of pudendal N block Incomplete epidural anaesthesia Injection of LA in post. Fourchette . Ax for episiotomy & repair. 29-09-2014 Indraprastha Apollo Hospital, New Delhi 41

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