Anaesthesia For Cesarean Delivery

Presentation by : Dr Prabhakar Moderator : Dr Sunita Gupta.

Anaesthesia For Cesarean Delivery

HISTORY

Anaesthesia For Cesarean Delivery

Cesarean Delivery Birth of an infant through Laparotomy and Hysterotomy. Cesarean technique was commonly associated with the manner Julius caeser (100 BC) was born with continued presence of Caesers mother in his life when such operations were invariably fatal . Latin word -- Caedere and sectio both imply to cut.

Anaesthesia For Cesarean Delivery

Indications for Cesarean Delivery

Anaesthesia For Cesarean Delivery

Factors contributing to the increasing Cesarean Delivery Rate :
Maternal Factors : Increasing proportion of deliveries in nulliparous women Delayed childbearing and increasing maternal age Increasing prevalence of obesity Obstetrics Factors : Increasing use of labour induction Fewer vaginal breech deliveries Fewer instrument vaginal deliveries Fewer attempts at trail of labour after Caesarean delivery Increasing availability of Cesarean delivery in developing nations

Anaesthesia For Cesarean Delivery

Fetal Factors : Increasing incidence of fetal macrosomia Increasing incidence of Multiple Gestation Ex Utero intrapartum treatment (EXIT) procedures Practice environment factors : Concern for malpractice litigation Increased use of electronic fetal heart rate monitoring Concern for pelvic floor injury associated with vaginal birth Desire for scheduled procedures.

Anaesthesia For Cesarean Delivery

Indications for Cesarean Delivery

Maternal : Antepartum or intrapartum hemorrhage Arrest of labor Breech presentration Chorioamnionitis Deteriorating maternal condition (e.g severe preeclampsia) Dystocia Failure of induction of labour Genital herpes High order multiple gestation (or twin gestation in which twin A has breech presenatation) Maternal request Placenta previa Placental abruption Previous myomectomy Prior classic utyerine incision Uterine rupture

Anaesthesia For Cesarean Delivery

Fetal : Breech presentation or other malpresentation Fetal intolerance of labor Macrosomia Nonreassuring fetal status Prolapsed umbilical cord Obstetricain : Desire to avoid difficult forceps or vacuum delivery

Anaesthesia For Cesarean Delivery

Morbidity and Mortality

Anaesthesia For Cesarean Delivery

Anaesthetic Complications : Haemorrhage : Uterine atony Uterine lacerations Broad ligament hematoma Infection : Endometritis Wound infection

Complications of Cesarean Delivery :

Anaesthesia For Cesarean Delivery

Postoperative Complications: Cardiovascular: Venous thromboembolism Gastrointestinal : ileus, adhesions, injury Genitourinary : bladder or urethral injury Respiratoory : Atelecftasis, aspiration Chronic pain Future Pregnancy Risks : Placenta previa Placenta accreta Uterine rupture Obstetric hysterectomy

Anaesthesia For Cesarean Delivery

Anaesthesia For Cesarean Delivery

Prevention of Cesarian Delivery

Anaesthesia For Cesarean Delivery

Neuraxial labour analgesic techniques were thought to increase the cesarean delivery rate. RCT have indicated that epidural analgesia is not associated with a higher cesarean delivery rate than systemic opioid analgesia .

Anaesthesia For Cesarean Delivery

Some Cesarean deliveries may be avoided through the provision of Adequate labor analgesia, including analgesia for trial of labor after cesarean delivery and instrumental vaginal delivery . Analgesia for External Cephalic Version Intrauterine resuscitation including pharmacologic uterine relaxation in cases of uterine tachysystole.

Anaesthesia For Cesarean Delivery

Obstetric management of Nonreassuring Fetal status : Optimize maternal position: Administer supplemental oxygen Maintain maternal circulation :
To avoid or relieve Aortocaval compression To relieve umbilical cord compression

Discontinue oxytocin Consider administration of tocolytic agent for treatment of uterine tachysystole or hypertonus.

Perform rapid intravenous administration of a non dextrose containing, balanced salt solution. Treat hypotension with either ephedrine or phenylephrine

Anaesthesia For Cesarean Delivery

Preparation of Anaesthesia

Anaesthesia For Cesarean Delivery

Preanaesthetic evaluation : A focused preanaesthetic history and physical examination includes
A review of maternal health and anaesthetic history, relevant obstetric history, allergies, and baseline blood pressure and heart rate measurements. Performance of airway , heart, and lung examination consistent with ASA guidelines.

Anaesthesia For Cesarean Delivery Informed consent :

Anaesthesia For Cesarean Delivery Blood Products :

Peripartum hemorrhage remains a leading cause of maternal mortality worldwide
Risk factors for peripartum hemorhage are listed
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Abnormal placentation Advanced maternal age Anticoagulation Bleeding disorder Chorioamnionitis Fetal demise Fetal malpresentation General anaesthesia Increased parity/grand parity Instrumental vaginal delivery

Anaesthesia For Cesarean Delivery

11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. Internal trauma (Internal version, curettage) Oxytocin augmentation of labor Placental abruption Precip[itous delivery Preeclampsia (Thrombocytopenia, coagulopathy) PROM Previous uterine surgery(Cesarean delivery, myomectomy) Proilonged labour Retained placenta Toccolytic therapy Trauma (blunt or penetrating) Uterine distention (Macrosomia, Multiple gestation, polyhyromnios) Uterine leiomyoma

Anaesthesia For Cesarean Delivery

Monitoring :
Pulse oximetry ECG Non invasive BP monitoring FHR monitoring (Fetal scalp or buttock ECG)

Anaesthesia For Cesarean Delivery

Equipment and Suggested resources for obstetrics Anaesthesia

Anaesthesia For Cesarean Delivery

Gastric emptying of clear liquids in pregnancy occurs relatively quickly. It has been known that gastric emptyinh half time of 300 ml of water is shorter than that of 50 ml of water in healthy, nonobese, non laboring pregnant women . Thus uncomplicated patient undergoing elective cesarean may drink modest amount of clear liquids upto 2 hrs before induction . A fasting of 6 to 8 hrs is required for solids . For prophylaxis H2 receptor antagonist reduces secretion of gastric juice Metoclopramide is a prokinetic and hasten gastric emptying. Omeprazole achieves higher gastric Ph than ranitidine.

Aspiration Prophylaxis

Anaesthesia For Cesarean Delivery Prophylactic Antibiotics :

Incidence and severity of post cesarean infection especially endometritis is reduced. Benefits are equal when given before abdominal incision or immediately after umbilical cord clamping .

Anaesthesia For Cesarean Delivery

Other preparations before cesarean surgery are :
Aseptic technique should be used Intravenous Access and Fluid management
Traditionally 1 to 1.5 L crystalloid is administrered to prevent or reduce the incidence and severity of hypotension Prehydration with crystalloid does not reliably prevent neuraxial anaesthesia induced hypotension

Supplemental medication for anxiety

Anaesthesia For Cesarean Delivery

After 20 wks gestation , all pregnanat women swhould be positioned with left uterine displacemtn to minimize aortocaval compression . Supine Hupotensive syndrome : manifests as pallor, tachycardia, sweating, nausea, vomiting and dizziness. Left lateral tilt of minimum 15 degrees is beneficial . The use of slight 10 degrees head up position is beneficial to reduce incidence of hypotension after initiation of hyperbaric spinal anaesthesia. This Ramp position is useful especially in sever obese females . Trendelenburg (Head down position) may augment venous return and reduce hypotension in spinal anaesthesia is questioned.

Positioning :

Anaesthesia For Cesarean Delivery

Evidence suggests that use of FiO2 of 0.35 to 0.4 does not improve fetal oxygenation. An FiO2 of 0.6 in non laboring women undergoing cesarean section with spinal anaesthesia may improve umbilical venous oxygen content by only 12% .

Supplemental oxygenation :

Anaesthesia For Cesarean Delivery Anaesthetic technique:

Anaesthesia For Cesarean Delivery

Overview of Neuraxial Anaesthetic Techniques

Anaesthesia For Cesarean Delivery

Local Anaesthetic used for Spinal Anaesthesia

Anaesthesia For Cesarean Delivery

Fentanyl : 2.5 to 60 mcg ; Pruritis, nausea, vomiting. 6.25mcg improves the quality and duration. Preservative free morphine : 0.1 to 0.25 mg ; provides 12 to 24 hrs post cesarean delivery analgesia. Diamorphine, sufentanil (2.5 to 20 mcg) has been used with bupivacaine in cesarean . Spinal clonidine : 60 to 150 mcg ; improves intraoperative analgesia and decreases shivering; hypotension and sedation side effects.

Adjuvant Agents

Anaesthesia For Cesarean Delivery Epidural anaesthesia :

Anaesthesia For Cesarean Delivery Extension of Epidural labor analgesia

Anaesthesia For Cesarean Delivery

General anaesthesia:

Anaesthesia For Cesarean Delivery Anaesthetic complications:

Awareness and Recall
The following factors contribute to the risk of maternal awareness during GA

Dysnoea:

Avoidance of sedative premedication Deliberate use of low concentration volatile halogenated dose during hypotension and hemorrhage Presence of partial neuraxial blockade requiring GA conversion.

The most common cause for for this complaint in neuraxial blockade is hypotension (causing hypoperfusion of the brain stem) and not high spinal Other causes are due to blunting of thoracic proprioception

Anaesthesia For Cesarean Delivery

Hypotension :
Common sequela of neuraxial anaesthetic techniques. Consequences of hypotension on fetus hypoxia, acidosis, and neonatal depression ; on mother unconsciousness pulmonary aspiration, apnoea, and cardiac arrest. The definition of maternal hypotension is controversial. Preoperative supine stress test would predict the occurrence of maternal symptoms . Supine stress test was considered positive if
Increase in maternal heart rate more than 10bpm A decrease in SBP of more than 15mmHg Signs and symptoms related to supine position in pregnanacy A decrease in SBP of more than 20 to 30% A decrease in SBP lower than 100 mmHg

Anaesthesia For Cesarean Delivery

High Neuraxial blockade :
Not uncommon T2 level involved. If impaired phonation , unconsciousness, respiratory depression .. Consider GA . High blockade can also result in CVS seqelae, including bradycardia and hypotension.

Anaesthesia For Cesarean Delivery

Nausea and vomiting.

Anaesthesia For Cesarean Delivery

Anaesthesia For Cesarean Delivery

Pruritis:

Anaesthesia For Cesarean Delivery

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