‘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:
1.Deploy other staff to secure the intravenous line
2.Preoxygenate 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 4.Local injection not mandatory
• Rapid sequence (limiting the 5.Add 25 mcg fentanyl, if there is time. If not
consider increasing the dose of bupivacaine
number of insertion attempts) 6.Only one attempt at spinal unless obvious
correction allows a successful second attempt
7.Start 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…