University of Gondar

College of medicine and health

science
SCHOOL OF MEDICINE

DEPARTMENT OF ANAESTHESIA
 In order to achieve core competencies, students at the end
of this course will be able to:
 Provide General anesthesia for elective and emergency
cesarean section
 Provide spinal anesthesia for elective and emergency
cesarean section .
 Administer anesthesia for pregnant women undergoing
non-obstetric surgery
 OUTLINE

 Introduction
 Preoperative assessment
 Spinal anesthesia for CS
 Epidural anesthesia
 General anesthesia
 INTRODUCTION
 Caesarean section (LSCS) is one of the commonest
operations performed in the developing world and is often
carried out in difficult circumstances
 WHO recommends an optimum caesarean section rate of 5-
15% to ensure best outcome for mother and neonate.
 Caesarean section itself is associated with a significant
morbidity and mortality
 and improvements in surgical and anaesthetic management can
reduce this.
 In a prospective study conducted in Latin America which
investigated more than 105,000 deliveries, mothers delivered by
caesarean section were over 2 times more likely to suffer from
severe maternal morbidity compared with vaginal delivery.
 The problems concern 5 areas:
 1. The patients
 2. The surgery (and the surgeon!)
 3. The drugs (both anaesthetic drugs and any

taken by the patient)

 4. Equipment
 5. The anaesthetist
 Problems with the patients
 2 paients

Problems with the surgery

Who is the surgeon, how experienced, how long does he

expect to take and what incision is planned?

Problems with drugs

The pregnant woman may be taking drugs for concurrent

diseases which have to be considered, e.g. steroids, anti
diabetic medication.
 Problems with equipment
 What anaesthetic equipment is available? Is there
adequate oxygen , either in cylinders or as a
functioning oxygen concentrator? Is the power supply
reliable? Does the sucker work and is there a back up
manually operated sucker? Does the table tilt and is
there a suitable wedge available?
 Problems with the anaesthetist
 Finally, you should consider how experienced you are with any
particular technique.
 Can you obtain the help of another anaesthetist?
 This is a good policy if you are expecting a difficult intubation
or other problems.
 do you have a trained assistant? Do they know how to do
cricoid pressure correctly? Having considered all the potential
difficulties, make a plan for your anaesthetic.
INDICATIONS FOR CESAREAN
DELIVERY
 Maternal
• Antepartum or intrapartum hemorrhage
• Arrest of labor
• Breech presentation
• Chorioamnionitis
• Deteriorating maternal condition (e.g., severe preeclampsia)
• Dystocia, Failure of induction of labor,Genital herpes (active
lesions), High-order multiple gestation (or twin gestation in which
twin A has a breech presentation)
 • Maternal request
• Placenta previa
• Placental abruption
• Previous myomectomy
• Prior classic uterine incision
• Uterine rupture
Fetal
• Breech presentation or other malpresentation
• Fetal intolerance of labor
• Suspected macrosomia
• Nonreassuring fetal status
• Prolapsed umbilical cord
COMPLICATIONS OF CESAREAN
DELIVERY

 Intraoperative Complications
Hemorrhage
• Uterine atony
• Uterine lacerations
• Broad ligament hematoma
Infection
• Endometritis
• Wound infection
 Postoperative Complications
• Cardiovascular: venous thromboembolism
• Gastrointestinal: ileus, adhesions, injury
• Genitourinary: bladder or ureteral injury
• Respiratory: atelectasis, aspiration pneumonia
• Chronic pain
Future Pregnancy Risks
• Placenta previa
• Placenta accreta
• Uterine rupture
• Obstetric hysterectomy
PREOPERATIVE ASSESSMENT

 Preoperative assessment is an important component of

managing obstetric patients and should not be underestimated.
 It allows you to build a rapport with your patient, and can alert
you to problems at an early stage, giving you time to formulate
a plan for the patient’s management
 preoperative assessment is very important for obstetric patients
because;
 It allows identification of mothers at higher risk of complications
during pregnancy and delivery (referred to as high-risk patients)
 Minimize risk for patients by planning their care - assistance may
be needed
 To know and decide the urgency of the
procedure(immediate,emergency,urgent and elective)
 Potential difficulties identified by obstetric staff early in
pregnancy, should ideally be referred to a senior anaesthetist in
a timely manner to jointly consider available options. E.g.
significant cardiac disease, obesity, difficult airway
 The anesthesia provider should consider the patient’s medical,
surgical, and obstetric history, the presence or absence of labor,
the urgency of the delivery, and the resources available in
preparing for a cesarean delivery
 who needs preoperative assessment in obstetrics?
 All patients requiring anaesthetic intervention

 This includes both general and regional anaesthesia

 In exceptional circumstances, there may not be time to
complete a full preoperative assessment, but a brief
assessment should still be completed.
 When should patients be seen for a preoperative assessment?
 As early as possible
 High risk patients should be seen around 30-34 weeks if possible so
that problems can be identified and management plans made for
delivery
 Patients for elective caesarean section can be seen in the days
preceding admission or as early as possible on the day of surgery
 All women admitted for labor and delivery are potential candidates for the
emergency administration of anesthesia, and an anesthesia provider ideally should
evaluate every woman shortly after admission.
 Pregnant women should be offered a haemoglobin assessment before CS to
identify those who have anaemia.
 Although blood loss of more than 1000ml is infrequent after CS (it occurs in 4 to
8% of CS)
 Pregnant women having CS for APH, are at increased risk of blood loss greater
than 1000 ml and should have the CS carried out at a maternity unit with on-site
blood transfusion services.
PREPARATION

 Antacid Prophylaxis • Antacid prophylaxis should be

prescribed to all women undergoing caesarean section.
 A combination of H2 antagonist (e.g. ranitidine) and
metaclopramide is frequently prescribed orally if time permits
and can be given IV in the emergency situation.
 These measures aim to increase gastric pH and reduce gastric
volume
PREPARATION

 Prescribe antibiotics (one dose of first-generation cephalosporin or

ampicillin)
 To reduce the risk of aspiration pneumonitis: Empty stomach, Pre-
medication with an antacid (sodium citrate 0.3% 30 mL or
magnesium trisilicate 300 mg) + Cimetidine IV 1 hr before CS
 Women having CS with regional anesthesia require an indwelling
urinary catheter to prevent over-distension of the bladder, because
the anaesthetic block interferes with normal bladder function
CATEGORY OF CESAREAN DELIVERY
 Category 1 (immediate): Immediate threat to life of woman
or fetus - decision to delivery time up to 30 mins.

Category 2 (emergency): Maternal or fetal compromise with

no immediate threat to life of woman or fetus – decision to
delivery time up to 1 hour

Category 3 (urgent): Requires early delivery - decision to

delivery time up to 24 hours

Category 4 (elective): No maternal or fetal compromise, at a

time to suit the woman and maternity services
 Spinal Anaesthesia for Caesarean Section
 A single shot spinal should reliably produce adequate
anaesthesia within 10-20 minutes of injection. In
obstetrics it may effective with in 5 minute.
 It is the technique of choice for most obstetric
anaesthetists for caesarean section where there is no
existing labour epidural
 It can be used in the elective and in all but the most
urgent of cases where general anaesthesia may be more
appropriate.
 Spinal spread is greater in pregnant compared with non-pregnant

women.

 Technique

Patient positioning
 Sitting

 Lateral
 needle
 Pencil Point (e.g.Whitacre, Sprotte) o Less likely to cause

PDPH

 Cutting (e.g. Quincke) If used, use smallest possible gauge

and insert cutting edge in saggital plane.

 Gauge , PDPH is related to size of needle – 25G and 27G

pencil point commonly used

Figure . Aseptic precautions (surgical cap, mask, gown,
gloves, and large sterile drape).
 Introducer
 Reduces deviation of small gauge spinal needles
 Approach •
 Midline

 Paramedian

Factor affecting spread of spinal anesthesia

 Baricity of local anaesthetic solution
 Dose

 Barbotage, –Pressure
 Speed of injection, volume
 Position during and after injection
 Height (extremely short or tall)
 Spinal column anatomy
 Decreased cerebrospinal fluid volume (increased intra-
abdominal pressure due to increased weight, pregnancy,
etc.
 Site of injection
 Needle bevel direction
 Figure . Spinal needle designs: (A) Whitacre,
(B) Sprotte, (C and D) Quincke (side and front
profiles).
Intrathecal opioids
•Intrathecal opioids have a synergistic effect with local anaesthetic
agents and act
• directly on opioid receptors in the spinal cord. They may:
• Reduce intraoperative discomfort. Dense block
• Prolong spinal analgesic action
• Provide postoperative analgesia and reduce postoperative
opioid requirements
• What are opioid Complications?
 epidural

Agent Intrathecal

5mg
Morphine 0.25–0.5 mg

50-100mg
Meperidine 10–25 mg

Fentanyl 12.5–25ug 50-150ug

Sufentanil 3–10 ug 10-20ug

LOCAL ANESTHETICS
 Drug Dose Range Duration (min)a
 Local Anesthetics

 Lidocaine 60–80 mg 45–75

 Bupivacaine 7.5–15 mg 60–120
 Levobupivacaine 7.5–15 mg 60–120
 Ropivacaine 15–25 mg 60–120

 Adjuvant
 Epinephrine 100–200 µg

(0.1–0.2 mg)
Advantages of spinal compared with epidural anaesthesia for

caesarean section

• Quicker to perform

• Produces more reliable block with faster onset

• Less trauma to epidural space

• Avoids epidural catheter related complications

Disadvantages compared with epidural

• Increased risk of hypotension and placentalinsufficiency

• No means of top up if surgery is prolonged

ADVANTAGES OF SPINAL ANESTHESIA
OVER GA
 1. Simplicity of technique
2. Minimal fetal exposure to the drug(s)
3. An awake parturient
4. Minimization of the hazards of aspiration

5. Cost

6. Respiratory disease

7. Patent airway

8.Diabetic patients 9. Muscle relaxation

10. Bleeding


COMPLICATIONS OF SPINAL
ANESTHESIA
 Nausea and vomiting
 Hypotension
 Shivering
 Postdural puncture headache
 Total and high spinal anesthesia
 Itch
 Transient mild hearing impairment
 Urinary retention
 Failed spinal, local anesthesia toxicity
COMPLICATIONS OF SPINAL ANESTHESIA

 Direct needle trauma

 Infection (abscess, meningitis)
 Vertebral canal hematoma
 Spinal cord ischemia
 Cauda equina syndrome
 Arachnoiditis
 Contraindications for Spinal Anesthesia
for Cesarean Section
 1. Severe maternal bleeding
2. Severe maternal hypotension
3. Coagulation disorders
4. Some forms of neurological disorders
5. Patient refusal
6. Technical problems
7. Short stature and morbidly obese parturients due to the fear of
high spinal block
 Failed or Inadequate Spinal Anaesthesia

 The potential aetiology of failure can be

 anatomical
 Failure of dural puncture with the spinal needle due to
spinal abnormalities such as kyphosis, scoliosis, limitation
of spinal flexion, or calcified ligaments
 Failure of local anaesthetic spread caused by adhesions or
septae in the epidural space (eg secondary to previous
surgery)
 Technique:
 * Loss of drug between the needle hub and syringe, or partial
deposition of the anaesthetic solution in the subdural or epidural
space resulting in an inadequate effect despite obtaining flow of
cerebrospinal fluid in the spinal needle.
 The aperture in the pencil-point needle straddling the dura, or a
dural tag; if there is no (or very slow) flow of cerebrospinal fluid in
the spinal needle, gentle and slight rotation of the spinal needle may
move the dural tag and allow good flow of cerebrospinal fluid.
 Drug error:
* Incorrect intrathecal drug administration, which can be disastrous; for
example Patel et al identified 21 reported cases of intrathecal tranexamic
acid injection, of which 20 resulted in life-threatening conditions and 10
were fatal.

 Equipment:
* Blocked spinal needle, resulting in a dry tap despite the needle tip
entering the subarachnoid space
SUMMARY

 Loss of injectate
 Inadequate intrathecal spread
 Infective drug action
 Misplaced injection
 Failed lumbar puncture: (‘dry tap’)

- Blocked needle

- Poor patient position

 Pseudo successful lumbar puncture
 Solutation injection error
 Drug Resistance
Types of failure
1. No block

 The wrong solution has been injected, it

has been deposited in the wrong place, or
it is ineffective.
 Repeating the procedure or conversion
to general anesthesia are the only option.
2. Good block of inadequate cephalad spread:

 The level of injection was too low,

- Anatomical abnormality has restricted spread,

or some injectate has been misplaced.

Unilateral block

 This is most likely because of positioning

 Turning the patient onto the unblocked side if a

hyperbaric solution was used (or the reverse for plain
solutions) may facilitate spread
 Patchy block
• A block that appears adequate in extent, but the sensory
and motor effects are incomplete.): The most likely
explanation is that the local anaesthetic was at least
partially misplaced, or that the dose given was
inadequate.

• If this becomes apparent before surgery starts, the

options are to repeat the spinal injection or to use a
greater degree of systemic supplementation than was
planned
Inadequate duration
Epidural Anaesthesia for Caesarean Section

 Epidural top up is an increasingly popular technique for

providing anaesthesia for caesarean section as a result of the

rising numbers of epidurals inserted for labour pain relief.

 The quality of the block is often inferior to spinal anaesthesia

COMPARISON OF SPINAL &
EPIDURAL ANESTHESIA
 Advantages compared with spinal
 If epidural in-situ, prevents risk of undergoing a further
procedure.
 Hypotension less pronounced
 Ability to maintain anaesthesia if prolonged procedure
 Option for postoperative analgesia
 Disadvantages compared with spinal
 Increases time taken to establish block suitable for surgery

 Less dense block and possibility of missed segments and

intraoperative pain

 Sacral block can be problematic

 Lower extent of block must be documented

 Combined Spinal / Epidural (CSE) for Caesarean Section

Combines advantages (and disadvantages) of both

techniques
 Rapid onset of spinal block
 Ability to modify / top-up / prolong anaesthesia with
epidural component
Spread of spinal anaesthetic can be increased with injection
of saline into the epidural space (compression effect of dural
sac)
Option for post-op analgesia
 Able to use lower dose spinal and modify if required

 Reduces need for conversion to general anaesthetic in event of

spinal failure

 Can produce a denser block than either technique in isolation

 Disadvantages •
 Potential increased risk – two procedures
 Higher failure rate than individual procedures
 Increased time to perform
 CSE kits more expensive
 Theoretical increased risk of meningitis (breached dura and
indwelling catheter)
GENERAL ANAESTHESIA FOR
CAESARIAN

 General anaesthesia in the obstetric patient is associated with an

increased risk of morbidity and mortality including airway
difficulties and failed intubation.
 Maternal mortality as a direct result of anaesthesia has fallen as
more caesareans are performed under regional anaesthesia.
 As a consequence of this trend, trainee anaesthetists are now more
limited in their exposure to general anaesthesia for caesarean
section.
 In certain emergent situations (e.g., fetal bradycardia,maternal
hemorrhage or coagulopathy, uterine rupture, maternal
trauma)general anesthesia may be needed for cesarean delivery
because of its rapid and reliable characteristics.
GENERAL ANESTHESIA
 The advantages of general anesthesia are as follows:
1. Speed of induction
2. Reliability
3. Controllability 4. Avoidance of hypotension
The following are disadvantages of general anesthesia:
1. Possibility of maternal aspiration
2. Problems of airway management
3. Narcotization of the newborn
4. Maternal awareness during light general anesthesia
 There are significant challenges associated with general

anaesthesia (GA) in the pregnant woman

 Changes in maternal physiology and anatomy present their own

challenges but can also exacerbate pre-existing medical problems.

 Specific conditions such as pre-eclampsia and massive maternal

haemorrhage significantly increase the risks of GA.

 GA in the obstetric population is often performed in a stressful and

pressured emergency situation.

 The physiological changes of pregnancy which contribute to the
challenges of general anaesthesia are considered below:
 Respiratory, Increased risk of difficult intubation due to:
 Airway oedema
 Enlarged breasts and weight gain
 Rapid desaturation on induction due to:
 displaced diaphragm and reduced FRC.
 Increased closing capacity and small airway closure.
 • Increased oxygen consumption.
 Attention to effective preoxygenation
 action Regular failed intubation drill.
 Access and familiarity with

difficult airway equipment

 Cardiovascular
 Decreased preload, decreased cardiac output
 and placental perfusion due to Aorto-caval compression by gravid
uterus
 Action Maintain left lateral tilt of 15 during induction and until baby
delivered.

 Expanded plasma volume, physiological anaemia, decreased

peripheral vascular resistance and increased cardiac output
 action recognition that pregnant women may appear relatively
stable but may decompensate quickly
 Coagulation
 Hypercoaguable state.
 Consideration of thromboprophylaxis incl.
 compression stockings, early mobilisation, prophylactic low
molecular weight heparin
 Gastrointestinal
 Increased Intra-abdominal pressure and progesterone
mediated reduction in lower oesophageal sphincter tone
increase risk of reflux and acid aspiration
syndrome(Mendelson’s).
 Labour reduces gastric emptying, especially if opioid
analgesia used.
 action
 Prophylactic H2 antagonists.
 Sodium citrate immediately prior to induction.
 Rapid sequence induction with cricoid pressure
 General anesthesia principle

 Induction time to delivery is important as it dictates the

amount of volatile anaesthetic agent that transfers to the
neonate.
 Uterine incision to delivery is important as placental blood
flow may be disrupted by uterine incision and if prolonged
may increase the risk of fetal acidosis.
 Use of prokinetics (e.g. metoclopramide 10 mg I.V) •
 Use of H2 antagonists (e.g. Ranitidine 150mg p.o if time
permits or 50mg I.V prior to an emergency)
 Sodium citrate (30ml) p.o just prior to induction
 Cricoid Pressure
 10N
 30N

Rapid Sequence Induction

• Choice of Induction Agent
• Thiopentone 4 mg/kg
• Ketamine 1-1.5mg/kg
• Propofol
• etomidate
 Inhalational Induction
 risk of aspiration and the increased risk of uterine atony and
haemorrhage due to uterine muscle relaxation caused by
volatile agents.

Neuromuscular Blockade

Suxamethonium

Non-Depolarising (Rocuronium)
 Opioids
 Although not routinely used at induction because of fears
of neonatal respiratory depression, short acting opioids
have a place in general anaesthesia for patients with
hypertensive disorders, primarily pre-eclampsia, to
reduce the risk of cerebral complications from the pressor
response of laryngoscopy.
Steps to follow when giving General anesthesia are include;
1.Administer a nonparticulate oral antacid (sodium citrate) before
induction of anesthesia with consideration for metoclopramide or a
histamine-2 blocker
2. Place standard monitors, maintain left uterine displacement, and ensure
suction, airway equipment, and appropriate drugs are readily available.

3. Ensure the patient has a working intravenous catheter and start an

infusion of crystalloid solution.preload ?
4. administer prophylactic antibiotics and participate in time-out checklist.
 5. Preoxygenate/denitrogenate patient for more than 3
minutes or 4 maximal (vital capacity) breaths over 30
seconds with 100% oxygen.
6. When the surgeon is ready and patient prepared, an
assistant should apply cricoid pressure (and maintain
until the position of the endotracheal tube is verifed).*
7. Notify and confrm with the surgeon that the patient is
ready for induction of anesthesia.
 8.Administer induction agent and muscle relaxant in rapid
sequence, wait 30 to 60 seconds, and then initiate direct
laryngoscopy for tracheal intubation. Consider using etomidate
or ketamine if concern for hypotension exists.
9. After confrming endotracheal tube placement, communicate
to surgeon to proceed with incision.
10. Administer 50% nitrous oxide in oxygen with 0.5 to 0.75
minimum alveolar concentration of a halogenated anesthetic.
11. Adjust minute ventilation to maintain normocarbia (end-tidal
carbon dioxide 30 to 32 mm Hg).
12. After delivery, anesthesia may be augmented by adminis
tering opioids, barbiturates, or propofol while continuing the
volatile anesthetic. Additional muscle relaxant may be
considered if necessary.
13. Administer oxytocin and assess uterine tone.
14. Extubate the trachea when the patient is awake and follow
ing commands and neuromuscular blockade is fully reversed.
 Extubation
 The risks of extubation are often overlooked but it is
associated with airway difficulties, including upper airway
obstruction, laryngospasm and aspiration.
 The left lateral position is recommended
RAPID SEQUENCE INDUCTION (RSI)

 Rapid sequence induction (RSI) is a method of achieving

rapid control of the airway whilst minimising the risk of
regurgitation and aspiration of gastric contents.
 Intravenous induction of anaesthesia, with the application
of cricoid pressure, is swiftly followed by the placement of
an endotracheal tube (ETT)
 RSI is only required in patients with preserved airway
reflexes.
 Indication ?

 RSI was originally described in 1961 by Sellick1 as:

 • Emptying of the stomach via a gastric tube which is then
removed
 Pre-oxygenation
 Positioning the patient supine with a head-down tilt
 Induction of anaesthesia with a barbiturate (e.g. thiopentone) or
volatile,and a rapid-acting muscle relaxant (e.g. suxamethonium)
 • Application of cricoid pressure
 Laryngoscopy and intubation of the trachea with a cuffed tube
immediately following fasciculations

Modified RSI’

Omitting the placement of an oesophageal tube

• Supine or ramped positioning

• Titrating the dose of induction agent to loss of consciousness

• Use of propofol, ketamine, midazolam or etomidate to
induce anaesthesia
Use of high-dose rocuronium as a neuromuscular blocking agent

Omitting cricoid pressure

PREPARATION

 Preparation is vital, both of equipment and team

members – particularly if the team is unfamiliar with the
environment or their colleagues.
THE END