‘Amang’ Rodriguez Memorial Medical Center

Sumulong Highway, Marikina City

Department of Anesthesiology

Case Discussion

LOUIJE P. MOMBAEL
ARMMC - POST GRADUATE INTERN
OBJECTIVES:

To present a case of a parturient for an emergency cesarean section

To discuss the Preoperative Survey

To discuss the Intraoperative Management

To discuss the Postoperative Care

CASE SCENARIO

• A 22 year old female G1P0 39 weeks age of gestation was brought to

the OB admitting section for imminent delivery. The patient was
diagnosed to have pre-eclampsia, as her blood pressure was
uncontrolled. The patient was brought to our institution by her
husband. She came from her house wherein she just had a full meal.
CASE SCENARIO

• Presently at the ER, the patient is Glasgow Coma Scale 15, with vital
signs of 160/100 mmHg, heart rate of 104 BPM, respiratory rate of 19
CPM, and O2 saturation of 96% on room air.
• On initial physical exam, patient is awake, conscious and coherent.
Her abdomen is enlarged to the gravid uterus, and she has grade 2
bipedal edema on both lower extremities.
• The OB Gyne service is planning to immediately operate on the
patient to do emergency primary Caesarian section due to
deteriorating maternal status.
GUIDE QUESTIONS

• Preoperative Survey
 What other pertinent questions should you ask in the history of the patient?
 What laboratories will you request?
• Intraoperative Management
 What type of anesthesia will you use?
 How will you induce the patient?
• Postoperative Care
 What pain medications will you use for this patient?
INTRODUCTION
• Most common indications for CS delivery:
 Arrest of dilation
 Non-reassuring fetal status
 Cephalopelvic disproportion
 Malpresentation,
 Prematurity,
 Prior cesarean delivery,
 Prior uterine surgery involving the corpus.
• Choice of anesthesia depends on
 Urgency of the procedure
 Condition of the mother and the fetus
 Mother’s wishes
INTRODUCTION
Indian J Anaesth. 2018 Sep; 62(9): 704–709.
doi: 10.4103/ija.IJA_590_18
PMCID: PMC6144558
PMID: 30237596
Anaesthetic management of obstetric emergencies

Table 1 Table 2
Indications for emergency caesarean sections Choice of anaesthesia in urgent caesarean sections

Table 3
Classification of urgency of caesarean section
 PREOPERATIVE SURVEY
• Past and current medical history
• Surgical history
• Family history
• Social history (tobacco, alcohol and illegal drugs)
• History of allergies
HISTORY

• Current and recent drug therapy

• Unusual reactions or responses to drugs
• Any problems or complications associated with previous anesthetics.
• A family history of adverse reactions associated with anesthesia.
• Complete review of systems (check for undiagnosed disease or inadequately controlled
chronic disease such as diseases of the cardiovascular and respiratory systems)
 PREOPERATIVE SURVEY

• Complete blood count

• Blood grouping and cross matching
laboratory

• Renal function (BUN, Creatinine)

• Liver function tests (AST, ALT)
• Coagulation profile (PT, PTT)
PREOPERATIVE PREPARATION

• Utero resuscitation of the fetus

• Administration of acid aspiration prophylaxis (Oral sodium citrate,
ranitidine and metoclopramide IV)
• Preparing for a potential difficult airway
• Securing IV access (2nd IV access ready)
• Invasive monitoring (if needed)
• All mothers coming for emergency caesarean sections are at high risk
of aspiration.
INTRAOPERATIVE MANAGEMENT

Mode of anesthesia
• Rapid sequence induction of general anesthesia unless contraindicated
• Alternative: spinal anesthesia and epidural anesthesia (especially if epidural
has already instituted for labor).
• Rarely: local infiltration.
 INTRAOPERATIVE MANAGEMENT
GENERAL ANESTHESIA

• Rapid delivery of the fetus is the via caesarean delivery specially when
there is threat to life of mother or fetus.
• Time taken to achieve surgical anesthesia should be kept as short as
possible.
• The role of anesthesiologists starts from the time of decision to deliver
by caesarean section is made.
• It includes maternal stabilization and in utero fetal resuscitation.
• Certain special considerations are to be kept in mind to conduct safe
general anaesthesia in challenging circumstances
 INTRAOPERATIVE MANAGEMENT
• All pregnant women are considered to be at high risk for aspiration due
to a relaxed esophageal sphincter caused by:
Prophylaxis against acid aspiration

Progesterone
Prolonged gastric emptying time
Pressure of gravid uterus on the diaphragm.
• Used to reduce acid aspiration and has risk for chemical pneumonitis:
H2 receptor antagonists (Ranitidine 50 mg IV)
Proton-pump inhibitors (Pantoprazole 40 mg IV)
Prokinetic agents (Metaclopromide 10 mg IV)
• Sodium citrate is also preferred because of its advantage of
instantaneous action.
 INTRAOPERATIVE MANAGEMENT

• To prevent neonatal depression, induction of anesthesia is usually

carried out after the patient is catheterized.
Patient position

• Left lateral tilt is recommended to avoid aortocaval compression.

• 30° head-up tilt is preferred to be useful in improving maternal well-
being due to the increased functional residual capacity (FRC)
• Reduced breast interference to intubation and reduced gastro-
esophageal reflux.
 INTRAOPERATIVE MANAGEMENT

• FRC is reduced by 40% at term gestation and oxygen consumption is

Preoxygenation

increased by 20%, oxygen reserves get rapidly depleted.

• Pre-oxygenation of 100% oxygen using a tight-fitting face mask that can
be achieved by tidal volume breathing for 3 min or performing 4 to 8
vital capacity breaths.
 INTRAOPERATIVE MANAGEMENT

• Rapid-sequence technique is preferred for general anesthesia.

Intravenous induction agents

• Thiopentone and succinylcholine are currently the agents of choice.

• Rocuronium–sugammadex combination might replace succinylcholine
• Propofol is generally not preferred due to poorer neonatal profile,
shorter duration of amnesia potentially leading to awareness and
longer time to recovery of spontaneous ventilation.
• Others: etomidate and ketamine.
 INTRAOPERATIVE MANAGEMENT

• Ideally cricoid pressure of 10 N should be applied on the cricoid

Cricoid pressure

cartilage towards the body of C6 vertebra, and the pressure should be

directed perpendicular to the tilted table.
• Increased pressure to 20 to 40 N after induction and kept in place until
tracheal intubation with ETCO2 is confirmed and till the cuff of the
tracheal tube is inflated.
 INTRAOPERATIVE MANAGEMENT

• It has ability to transfer thru placental it cause the incidence of low

APGAR in neonates
• It is usually avoided in obstetric cases till the extraction of fetus.
• Suppress the laryngeal reflexes during laryngoscopy,
Opioids

• Non-opioid drugs (esmolol, nitroglycerine and magnesium sulphate)

can be used.
 Complication(s): severe cardiac disease or hypertensive disorder
• Ultra-short-acting opioids (remifentanil or fentanyl) provided this
information is passed onto attending neonatologist.
 INTRAOPERATIVE MANAGEMENT
Supraglottic airway devices for general
anesthesia in obstetric patients

• Rescue devices that can be used to maintain oxygenation with difficult

mask ventilation or those with difficult intubation.
• Second generation supraglottic airway devices hold great potential in
the management of the obstetric airway.
• LMA Proseal™ incorporates a second tube intended to permit
continuity with the gastrointestinal tract and isolation from the airway,
minimizing gastric insufflations during positive-pressure ventilation.
 INTRAOPERATIVE MANAGEMENT
• Minimum monitoring standards as per ASA is advised during general
anesthesia in obstetric patients.
• Monitor the end-tidal carbon dioxide (ETCO2)
• beneficial in preventing esophageal intubation
Perioperative care

• Endobronchial intubation.
• Anesthesia is generally maintained with inhalation agents such as isoflurane
and sevoflurane.
• Halothane is  uterine-relaxant effect. (usually avoided)
• Nitrous oxide is rapid onset and intra-operative analgesia.
• End-tidal agent monitoring can be used to titrate the anesthetic depth.
• FiO2 level is guided by the underlying maternal and fetal conditions.
 INTRAOPERATIVE MANAGEMENT

• Risk of aspiration in unprotected airway,

• Parturient is fully awake, with adequate reversal of residual neuromuscular
block and pain free before considering for extubation.
Extubation

• Risk of cannot intubate cannot ventilate situation is a major

disadvantage of general anesthesia.
• The risk of failed intubation in pregnancy is at least 8 times higher than
the general population.
 INTRAOPERATIVE MANAGEMENT
TOP-UP OF EPIDURAL

• If epidural was initiated earlier in labor

• Delivery time is as fast as that for general anesthesia
• Speed of onset (local anesthetics and adjuvants)
• Patient should be monitored prior to OR.
• If epidural analgesia during labor is poor consider converting to spinal
or general anesthesia.
 INTRAOPERATIVE MANAGEMENT
Sequence in a ‘Rapid Sequence Spinal’ are as
Rapid sequence spinal anesthesia

follows:
[Link] other staff to secure the intravenous line
[Link] during the attempt
• Skilled hands of anesthesiology 3.'No Touch Technique' use only gloves,
chlorhexidine on swab to paint and use glove
• Rapid as general anesthesia with packet as sterile surface
low failure rate [Link] injection not mandatory
• Rapid sequence (limiting the [Link] 25 mcg fentanyl, if there is time. If not
consider increasing the dose of bupivacaine
number of insertion attempts) [Link] one attempt at spinal unless obvious
correction allows a successful second attempt
[Link] surgery once sensory level >T10 and
ascending. Be ready for general anesthesia and
inform the mother.
INTRAOPERATIVE MANAGEMENT
Indian J Anaesth. 2018 Sep; 62(9): 704–709.
Failed intubation
doi: 10.4103/ija.IJA_590_18
PMCID: PMC6144558
PMID: 30237596
• 10 times more in the obstetric
Anaesthetic management of obstetric emergencies
population specially in obese
Table 5 patients.
Complications of caesarean section

Pulmonary aspiration
• mainly due progesterone  lower
esophageal sphincter tone
• mechanical displacement of the
stomach upwards by the gravid
uterus.
POSTOPERATIVE CARE
Post-cesarean delivery pain relief is
important.
• Improve mobility Most commonly used:
• Reduce the risk of thromboembolic • Systemic administration of
disease. opioids
• Pain and anxiety may also reduce  IM injection
the ability of a mother to breast-  IV by patient-controlled analgesia
feed effectively. • Neuraxial injection of opioid
 It should be safe and result in no
adverse neonatal effects in breast-
feeding mother.
 POSTOPERATIVE CARE
• Most commonly used modality for immediate post-cesarean delivery
SYSTEMIC ADMINISTRATION

pain relief, usually after general anesthesia.

• Analgesics may be given:
• IM
• IV (patient-controlled analgesia)
• Oral (if bowel function is normal).
• Advantage:
• Ease of administration
• Low cost
• Pain relief is less effective.
 POSTOPERATIVE CARE
Intrathecal Opioids:
• Used for post-cesarean delivery pain  Morphine
NEURAXIAL ANALGESIA

relief even in women having general  Fentanyl

 Meperidine
anesthesia, if patient desire but only  Sufentanil
once they are awake.  Nalbuphine
 Heroin
• A single dose at the time of cesarean delivery
Epidural Opioids: can provide excellent analgesia of prolonged
duration. 
• administered either as a bolus or as a
• Adverse effects:
continuous infusion for postoperative  Pruritus
• “nuisance” side effects that are easily  Nausea & vomiting
 Urinary retention
treated
 Early or delayed respiratory depression.
NSAIDS New Drugs

• It acts in the postoperative

(somatic) pain from the wound • Clonidine.
itself and visceral pain arising
• Dexmedetomidine.
from the uterus
• Neostigmine.
• Disadvantage:
 Gastrointestinal side effects • Lipid-Encapsulated Morphine.
 Platelet dysfunction
END…